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Ferrari D, Violante T, Bin Zubair A, Rumer KK, Shawki SF, Merchea A, Stocchi L, Behm KT, Lovely JK, Larson DW. Rethinking postoperative care: same-day ileostomy closure discharge improves patient outcomes. J Gastrointest Surg 2024; 28:667-671. [PMID: 38704204 DOI: 10.1016/j.gassur.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/19/2024] [Accepted: 02/07/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND The evolution of enhanced recovery pathways (ERPs) in colon and rectal surgery has led to the development of same-day discharge (SDD) procedures for selected patients. Early discharge after diverting loop ileostomy (DLI) closure was first described in 2003. However, its widespread adoption remains limited, with SDD accounting for only 3.2% of all DLI closures in 2005-2006, according to the American College of Surgeons National Surgical Quality Improvement Program database, and rising to just 4.1% by 2016. This study aimed to compare the outcomes of SDD DLI closure with those of DLI closure after the standard ERP. METHODS A retrospective case-matched study compared 125 patients undergoing SDD DLI closure with 250 patients undergoing DLI closure after the standard ERP based on age (±1 year), sex, American Society of Anesthesiologists score, body mass index, surgery date (±2 months), underlying disease, and hospital site. The primary outcome was comparative 30-day complication rates. RESULTS Patients in the traditional ERP group received more intraoperative fluids (1221.1 ± 416.6 vs 1039.0 ± 368.3 mL, P < .001) but had similar estimated blood loss. Ten patients (8%) in the SDD-ERP group failed SDD. The 30-day postoperative complication rate was significantly lower in the SDD group (14.8%) than the standard ERP group (25.7%, P = .025). This difference was primarily driven by a lower incidence of ileus in the SDD group (9.6% vs 14.8%, P = .034). There were no significant differences in readmission rate (9.6% of SDD-ERP vs 9.2% of standard ERP, P = .900) and reoperation rates (3.2% of SDD-ERP vs 2.4% of standard ERP, P = .650). CONCLUSION SDD ileostomy closure is a safe, feasible, and effective procedure associated with fewer complications than the present study's standard ERP. This could represent a new standard of care. Further prospective trials are required to confirm the findings of this study.
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Affiliation(s)
- Davide Ferrari
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, United States; General Surgery Residency Program, University of Milan, Milan, Italy
| | - Tommaso Violante
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, United States; Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Abdullah Bin Zubair
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kristen K Rumer
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Sherief F Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Luca Stocchi
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Jenna K Lovely
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota, United States
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, United States.
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Gomaa I, Aboelmaaty S, Narasimhan AL, Bhatt H, Day CN, Harmsen WS, Rumer KK, Perry WR, Mathis KL, Larson DW. The Impact of Enhanced Recovery on Long-Term Survival in Rectal Cancer. Ann Surg Oncol 2024; 31:3233-3241. [PMID: 38381207 DOI: 10.1245/s10434-024-14998-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/18/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Implementing perioperative interventions such as enhanced recovery pathways (ERPs) has improved short-term outcomes and minimized length of stay. Preliminary evidence suggests that adherence to the enhanced recovery after surgery protocol may also enhance 5-year cancer-specific survival (CSS) in colorectal cancer surgery. This retrospective study presents long-term survival outcomes and disease recurrence from a high-volume, single-center practice. METHODS All patients over 18 years of age diagnosed with rectal adenocarcinoma and undergoing elective minimally invasive surgery (MIS) were retrospectively reviewed between February 2005 and April 2018. Relevant data were extracted from Mayo electronic records and securely stored in a database. Short-term morbidity and long-term oncological outcomes were compared between patients enrolled in ERP and those who received non-enhanced care. RESULTS Overall, 600 rectal cancer patients underwent MIS, of whom 320 (53.3%) were treated according to the ERP and 280 (46.7%) received non-enhanced care. ERP was associated with a decrease in length of stay (3 vs. 5 days; p < 0.001) and less overall complications (34.7 vs. 54.3%; p < 0.001). The ERP group did not show an improvement in overall survival (OS) or disease-free survival (DFS) compared with non-enhanced care on multivariable (non-ERP vs. ERP OS: hazard ratio [HR] 1.268, 95% confidence interval [CI] 0.852-1.887; DFS: HR 1.050, 95% CI 0.674-1.635) analysis. CONCLUSION ERP was found to be associated with a reduction in short-term morbidity, with no impact on long-term oncological outcomes, such as OS, CSS, and DFS.
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Affiliation(s)
- Ibrahim Gomaa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sara Aboelmaaty
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Himani Bhatt
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kristen K Rumer
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - William R Perry
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
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Violante T, Murphy B, Ferrari D, Graham RP, Navin P, Merchea A, Larson DW, Dozois EJ, Halfdanarson TR, Perry WR. Presacral Neuroendocrine Neoplasms: A Multi-site Review of Surgical Outcomes. Ann Surg Oncol 2024:10.1245/s10434-024-15328-3. [PMID: 38679679 DOI: 10.1245/s10434-024-15328-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION Presacral neuroendocrine neoplasms (PNENs) are rare tumors, with limited data on management and outcomes. METHODS A retrospective review of institutional medical records was conducted to identify all patients with PNENs between 2008 and 2022. Data collection included demographics, symptoms, imaging, surgical approaches, pathology, complications, and long-term outcomes. RESULTS Twelve patients were identified; two-thirds were female, averaging 44.8 years of age, and, for the most part, presenting with back pain, constipation, and abdominal discomfort. Preoperative imaging included computed tomography scans and magnetic resonance images, with somatostatin receptor imaging and biopsies being common. Half of the patients had metastatic disease on presentation. Surgical approach varied, with anterior, posterior, and combined techniques used, often involving muscle transection and coccygectomy. Short-term complications affected one-quarter of patients. Pathologically, PNENs were mainly well-differentiated grade 2 tumors with positive synaptophysin and chromogranin A. Associated anomalies were common, with tail-gut cysts prevalent. Mean tumor diameter was 6.3 cm. Four patients received long-term adjuvant therapy. Disease progression necessitated additional interventions, including surgery and various chemotherapy regimens. Skeletal, liver, thyroid, lung, and pancreatic metastases occurred during follow-up, with no mortality reported. Kaplan-Meier analysis showed a 5-year local recurrence rate of 23.8%, disease progression rate of 14.3%, and de novo metastases rate of 30%. CONCLUSION The study underscores the complex management of PNENs and emphasizes the need for multicenter research to better understand and manage these tumors. It provides valuable insights into surgical outcomes, recurrence rates, and overall survival, guiding future treatment strategies for PNEN patients.
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Affiliation(s)
- Tommaso Violante
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- School of General Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Brenda Murphy
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Davide Ferrari
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- School of General Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Rondell P Graham
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Patrick Navin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - William R Perry
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
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Ferrari D, Violante T, Addison P, Perry WRG, Merchea A, Kelley SR, Mathis KL, Dozois EJ, Larson DW. Robotic resection of presacral tumors. Tech Coloproctol 2024; 28:49. [PMID: 38653930 DOI: 10.1007/s10151-024-02922-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/16/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Presacral tumors are a rare entity typically treated with an open surgical approach. A limited number of minimally invasive resections have been described. The aim of the study is to evaluate the safety and efficacy of roboticresection of presacral tumors. METHODS This is a retrospective single system analysis, conducted at a quaternary referral academic healthcare system, and included all patients who underwent a robotic excision of a presacral tumor between 2015 and 2023. Outcomes of interest were operative time, estimated blood loss, complications, length of stay, margin status, and recurrence rates. RESULTS Sixteen patients (11 females and 5 males) were included. The median age of the cohort was 51 years (range 25-69 years). The median operative time was 197 min (range 98-802 min). The median estimated blood loss was 40 ml, ranging from 0 to 1800 ml, with one patient experiencing conversion to open surgery after uncontrolled hemorrhage. Urinary retention was the only postoperative complication that occurred in three patients (19%) and was solved within 30 days in all cases. The median length of stay was one day (range 1-6 days). The median follow-up was 6.7 months (range 1-110 months). All tumors were excised with appropriate margins, but one benign and one malignant tumor recurred (12.5%). Ten tumors were classified as congenital (one was malignant), two were mesenchymal (both malignant), and five were miscellaneous (one malignant). CONCLUSIONS Robotic resection of select presacral pathology is feasible and safe. Further studies must be conducted to determine complication rates, outcomes, and long-term safety profiles.
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Affiliation(s)
- D Ferrari
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - T Violante
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- School of General Surgery, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - P Addison
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - W R G Perry
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - A Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - S R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - E J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA.
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Violante T, Ferrari D, Mathis KL, D'Angelo ALD, Dozois EJ, Merchea A, Larson DW. Robotic-assisted surgery conversion: the sooner, the better? Insights from a single-center study. J Gastrointest Surg 2024:S1091-255X(24)00402-5. [PMID: 38583579 DOI: 10.1016/j.gassur.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; School of General Surgery, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; General Surgery Residency Program, University of Milan, Milan, Italy
| | - Kellie L Mathis
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Anne-Lise D D'Angelo
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Eric J Dozois
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States.
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Violante T, Behm KT, Shawki SF, Ferrari D, D'Angelo ALD, Kelley SR, Nitin M, Larson DW. Robotic-assisted reoperative ileal pouch-anal anastomosis: robotic pouch excision and pouch revision. Tech Coloproctol 2024; 28:43. [PMID: 38561571 DOI: 10.1007/s10151-024-02918-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/09/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Up to 20% of patients with ileal pouch will develop pouch failure, ultimately requiring surgical reintervention. As a result of the complexity of reoperative pouch surgery, minimally invasive approaches were rarely utilized. In this series, we present the outcomes of the patients who underwent robotic-assisted pouch revision or excision to assess its feasibility and short-term results. METHODS All the patients affected by inflammatory bowel diseases and familial adenomatous polyposis who underwent robotic reoperative surgery of an existing ileal pouch were included. RESULTS Twenty-two patients were included; 54.6% were female. The average age at reoperation was 51 ± 16 years, with a mean body mass index of 26.1 ± 5.6 kg/m2. Fourteen (63.7%) had a diagnosis of ulcerative colitis at reoperation, and seven (31.8%) had Crohn's disease. The mean time to pouch reoperation was 12.8 ± 11.8 years. Seventeen (77.3%) patients underwent pouch excision, and five (22.7%) had pouch revision surgery. The mean operative time was 372 ± 131 min, and the estimated blood loss was 199 ± 196.7 ml. The conversion rate was 9.1%, the 30-day morbidity rate was 27.3% (with only one complication reaching Clavien-Dindo grade IIIB), and the mean length of stay was 5.8 ± 3.9 days. The readmission rate was 18.2%, the reoperation rate was 4.6%, and mortality was nihil. All patients in the pouch revisional group are stoma-free. CONCLUSION Robotic reoperative pouch surgery in highly selected patients is technically feasible with acceptable outcomes.
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Affiliation(s)
- Tommaso Violante
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- Department of Colon and Rectal Surgery, Mayo Clinic, Phoenix, ARZ, USA
- School of General Surgery, Alma Mater Studiorum, Università Di Bologna, Bologna, Italy
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Sherief F Shawki
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Davide Ferrari
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- Department of Colon and Rectal Surgery, Mayo Clinic, Phoenix, ARZ, USA
- School of General Surgery, Alma Mater Studiorum, Università Di Bologna, Bologna, Italy
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Anne-Lise D D'Angelo
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Scott R Kelley
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Mishra Nitin
- Department of Colon and Rectal Surgery, Mayo Clinic, Phoenix, ARZ, USA
| | - David W Larson
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA.
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Ferrari D, Violante T, Bhatt H, Gomaa IA, D'Angelo ALD, Mathis KL, Larson DW. Effect of previous abdominal surgery on robotic-assisted rectal cancer surgery. J Gastrointest Surg 2024; 28:513-518. [PMID: 38583904 DOI: 10.1016/j.gassur.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/04/2024] [Accepted: 01/13/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The effect of previous abdominal surgery (PAS) in laparoscopic surgery is well known and significantly adds to longer hospital length of stay (LOS), postoperative ileus, and inadvertent enterotomies. However, little evidence exists in patients with PAS undergoing robotic-assisted (RA) rectal surgery. METHODS All patients undergoing RA surgery for rectal cancer were reviewed. Patients with PAS were divided into minor and major PAS groups, defined as surgery involving >1 quadrant. The primary outcome was the risk of conversion to open surgery. RESULTS A total of 750 patients were included, 531 in the no-PAS (NPAS) group, 31 in the major PAS group, and 188 in the minor PAS group. Patients in the major PAS group had significantly longer hospital LOS (P < .001) and lower adherence to enhanced recovery pathways (ERPs; P = .004). The conversion rates to open surgery were similar: 3.4% in the NPAS group, 5.9% in the minor PAS group, and 9.7% in the major PAS group (P = .113). Estimated blood loss (EBL; P = .961), operative times (OTs; P = .062), complication rates (P = .162), 30-day readmission (P = .691), and 30-day mortality (P = .494) were similar. Of note, 53 patients underwent lysis of adhesions (LOA). On multivariate analysis, EBL >500 mL and LOA significantly influenced conversion to open surgery. EBL >500 mL, age >65 years, conversion to open surgery, and prolonged OT were risk factors for prolonged LOS, whereas adherence to ERPs was a protector. CONCLUSION PAS did not seem to affect the outcomes in RA rectal surgery. Given this finding, the robotic approach may ultimately provide patients with PAS with similar risk to patients without PAS.
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Affiliation(s)
- Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; General Surgery Residency Program, University of Milan, Milan, Italy
| | - Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; Surgery of the Alimentary Tract, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Himani Bhatt
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ibrahim A Gomaa
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Anne-Lise D D'Angelo
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kellie L Mathis
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States.
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Violante T, Ferrari D, Gomaa IA, Rumer KK, D'Angelo ALD, Behm KT, Shawki SF, Perry WRG, Kelley SR, Mathis KL, Dozois EJ, Cima RR, Larson DW. Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes. J Gastrointest Surg 2024; 28:501-506. [PMID: 38583902 DOI: 10.1016/j.gassur.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.
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Affiliation(s)
- Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; School of General Surgery, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; General Surgery Residency Program, University of Milan, Milan, Italy
| | - Ibrahim A Gomaa
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kristen K Rumer
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Anne-Lise D D'Angelo
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Sherief F Shawki
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - William R G Perry
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Scott R Kelley
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kellie L Mathis
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Eric J Dozois
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Robert R Cima
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States.
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Ferrari D, Violante T, Day CN, McKenna NP, Mathis KL, Dozois EJ, Larson DW. Unveiling the Hidden Consequences: The Initial Impact of COVID-19 on Colorectal Cancer Operation. J Am Coll Surg 2024:00019464-990000000-00916. [PMID: 38525960 DOI: 10.1097/xcs.0000000000001042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND The COVID-19 pandemic has severely affected healthcare systems globally, resulting in significant delays and challenges in various medical treatments, particularly in cancer care. This study aims to investigate the repercussions of the pandemic on surgical interventions for colorectal cancer in the United States, using data from the National Cancer Database (NCDB). METHODS We conducted a retrospective analysis of the NCDB, encompassing adult patients who underwent surgical procedures for colon and rectal cancer in 2019 (pre-COVID) and 2020 (COVID). We examined various demographic and clinical variables, including patient characteristics, tumor staging, surgical approaches, and socioeconomic factors. RESULTS The analysis included 105,517 patients, revealing a 17.3% reduction in surgical cases during the initial year of the pandemic. Patients who underwent surgery in 2020 displayed more advanced clinical and pathological tumor stages compared to those treated in 2019. After diagnosis, no delay was reported in the treatment. Patients operated during the pandemic, African American patients, uninsured and Medicaid beneficiaries had worse stage colon and rectal cancer, and individuals with lower incomes bore the burden of advanced colon cancer. CONCLUSIONS The impact of the COVID-19 pandemic on colorectal cancer surgery transcends a mere decline in case numbers, resulting in a higher prevalence of patients with advanced disease. This study underscores the exacerbated disparities in cancer care, particularly affecting vulnerable populations. The COVID-19 pandemic has left a significant and enduring imprint on colorectal cancer surgery, intensifying the challenges faced by patients and healthcare systems. Comprehensive studies are imperative to comprehend the long-term consequences of delayed screenings, diagnoses, and treatments, as healthcare planning for the future must consider the unintended repercussions of pandemic-related disruptions.
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Affiliation(s)
- Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
- School of General Surgery, Alma Mater Studiorum Università di Bologna, Bologna, Italy
- Department of Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
- School of General Surgery, Alma Mater Studiorum Università di Bologna, Bologna, Italy
- Department of Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | - Kellie L Mathis
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Eric J Dozois
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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10
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Ferrari D, Violante T, Novelli M, Starlinger PP, Smoot RL, Reisenauer JS, Larson DW. The death of laparoscopy. Surg Endosc 2024:10.1007/s00464-024-10774-2. [PMID: 38519609 DOI: 10.1007/s00464-024-10774-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/24/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The introduction of laparoscopy in 1989 revolutionized surgical practices, reducing post-operative complications, and enhancing outcomes. Despite its benefits, limitations in laparoscopic tools have led to continued use of open surgery. Robotic-assisted surgery emerged to address these limitations, but its adoption trends and potential impact on open and laparoscopic surgery require analysis. METHODS A retrospective analysis used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases from 2012 to 2021. The study encompassed various abdominal procedures, employing Vector Autoregressive (VAR) models to analyze the dynamic relationships between surgical techniques. The models predicted future trends in open, laparoscopic, and robotic surgery until Q2 of 2025. RESULTS The analysis included 360,171 patients across diverse procedures. In urology, robotic surgery dominated prostatectomies (83.1% in 2021) and nephrectomies (55.1% in 2021), while the open approach remained the predominant surgical technique for cystectomies (72.5% in 2021). In general surgery, robotic colectomies were forecasted to surpass laparoscopy, becoming the primary approach by 2024 (45.7% in 2025). Proctectomies also showed a shift towards robotic surgery, predicted to surpass laparoscopy and open surgery by 2025 (32.3%). Pancreatectomies witnessed a steady growth in robotic surgery, surpassing laparoscopy in 2021, with forecasts indicating further increase. While hepatectomies remained predominantly open (70.0% in 2025), esophagectomies saw a rise in robotic surgery, predicted to become the primary approach by 2025 (52.3%). CONCLUSIONS The study suggests a transformative shift towards robotic-assisted surgery, poised to dominate various minimally invasive procedures. The forecasts indicate that robotic surgery may surpass laparoscopy and open surgery in colectomies, proctectomies, pancreatectomies, and esophagectomies by 2025. This anticipated change emphasizes the need for proactive adjustments in surgical training programs to align with evolving surgical practices. The findings have substantial implications for future healthcare practices, necessitating a balance between traditional laparoscopy and the burgeoning role of robotic-assisted surgery.
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Affiliation(s)
- Davide Ferrari
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Tommaso Violante
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- School of General Surgery, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marco Novelli
- Department of Statistics, University of Bologna, Bologna, Italy
| | - Patrick P Starlinger
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Janani S Reisenauer
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA.
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11
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Mirnezami AH, Drami I, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Denys A, Pape E, van Ramshorst GH, Baker D, Bignall E, Blair I, Davis P, Edwards T, Jackson K, Leendertse PG, Love-Mott E, MacKenzie L, Martens F, Meredith D, Nettleton SE, Trotman MP, van Hecke JJM, Weemaes AMJ, Abecasis N, Angenete E, Aziz O, Bacalbasa N, Barton D, Baseckas G, Beggs A, Brown K, Buchwald P, Burling D, Burns E, Caycedo-Marulanda A, Chang GJ, Coyne PE, Croner RS, Daniels IR, Denost QD, Drozdov E, Eglinton T, Espín-Basany E, Evans MD, Flatmark K, Folkesson J, Frizelle FA, Gallego MA, Gil-Moreno A, Goffredo P, Griffiths B, Gwenaël F, Harris DA, Iversen LH, Kandaswamy GV, Kazi M, Kelly ME, Kokelaar R, Kusters M, Langheinrich MC, Larach T, Lydrup ML, Lyons A, Mann C, McDermott FD, Monson JRT, Neeff H, Negoi I, Ng JL, Nicolaou M, Palmer G, Parnaby C, Pellino G, Peterson AC, Quyn A, Rogers A, Rothbarth J, Abu Saadeh F, Saklani A, Sammour T, Sayyed R, Smart NJ, Smith T, Sorrentino L, Steele SR, Stitzenberg K, Taylor C, Teras J, Thanapal MR, Thorgersen E, Vasquez-Jimenez W, Waller J, Weber K, Wolthuis A, Winter DC, Brangan G, Vimalachandran D, Aalbers AGJ, Abdul Aziz N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Baker RP, Bali M, Baransi S, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Bui A, Burgess A, Burger JWA, Campain N, Carvalhal S, Castro L, Ceelen W, Chan KKL, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Damjanovic L, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Egger E, Enrique-Navascues JM, Espín-Basany E, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Fleming F, Flor B, Foskett K, Funder J, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Giner F, Ginther N, Glover T, Golda T, Gomez CM, Harris C, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Jenkins JT, Jourand K, Kaffenberger S, Kapur S, Kanemitsu Y, Kaufman M, Kelley SR, Keller DS, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Lago V, Lakkis Z, Lampe B, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lynch AC, Mackintosh M, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Morton JR, Mullaney TG, Navarro AS, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Pappou E, Park J, Patsouras D, Peacock O, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steffens D, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor D, Tejedor P, Tekin A, Tekkis PP, Thaysen HV, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Yano H, Yip B, Yip J, Yoo RN, Zappa MA. The empty pelvis syndrome: a core data set from the PelvEx collaborative. Br J Surg 2024; 111:znae042. [PMID: 38456677 PMCID: PMC10921833 DOI: 10.1093/bjs/znae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored. METHOD Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition. RESULTS One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed. CONCLUSIONS EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.
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Achilli P, Ferrari D, Calini G, Bertoglio CL, Magistro C, Origi M, Carnevali P, Alampi BD, Giusti I, Ferrari G, Calafiore E, Spinelli A, Grass F, Deslarzes P, Hahnloser D, Abdalla S, Larson DW. Preoperative lateral lymph node features and impact on local recurrence after neoadjuvant chemoradiotherapy and total mesorectal excision for locally advanced rectal cancer: results from a multicentre international cohort study. Colorectal Dis 2024; 26:466-475. [PMID: 38243617 DOI: 10.1111/codi.16875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/18/2023] [Accepted: 12/27/2023] [Indexed: 01/21/2024]
Abstract
AIM Locally advanced rectal cancer (LARC) is commonly treated with neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME) to reduce local recurrence (LR) and improve survival. However, LR, particularly associated with lateral lymph node (LLN) involvement, remains a concern. The aim of this study was to investigate preoperative factors associated with LLN involvement and their impact on LR rates in LARC patients undergoing nCRT and curative surgery. METHOD This multicentre retrospective study, including four academic high-volume institutions, involved 301 consecutive adult LARC patients treated with nCRT and curative surgery between January 2014 and December 2019 who did not undergo lateral lymph node dissection (LLND). Baseline and restaging pelvic MRIs were evaluated for suspicious LLNs based on institutional criteria. Patients were divided into two groups: cLLN+ (positive nodes) and cLLN- (no suspicious nodes). Primary outcome measures were LR and lateral local recurrence (LLR) rates at 3 years. RESULTS Among the cohort, 15.9% had suspicious LLNs on baseline MRI, and 9.3% had abnormal LLNs on restaging MRI. At 3 years, LR and LLR rates were 4.0% and 1.0%, respectively. Ten out of 12 (83.3%) patients with LR showed no suspicious LLNs at the baseline MRI. Abnormal LLNs on MRI were not independent risk factors for LR, distant recurrence or disease-free survival. CONCLUSION Abnormal LLNs on baseline and restaging MRI assessment did not impact LR and LLR rates in this cohort of patients with LARC submitted to nCRT and curative TME surgery.
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Affiliation(s)
- Pietro Achilli
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Mini-invasive Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Davide Ferrari
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Camillo L Bertoglio
- Department of Mini-invasive Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Carmelo Magistro
- Department of Mini-invasive Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Origi
- Department of Mini-invasive Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Pietro Carnevali
- Department of Mini-invasive Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Bruno D Alampi
- Department of Mini-invasive Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Irene Giusti
- Department of Mini-invasive Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanni Ferrari
- Department of Mini-invasive Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Philip Deslarzes
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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13
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Giron H, Kefleyesus A, Larson DW, Grass F. How I do it: a standardized approach to robotic-assisted oncological sigmoid resection - a video vignette. Colorectal Dis 2024; 26:578-579. [PMID: 38240160 DOI: 10.1111/codi.16881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/30/2023] [Indexed: 04/02/2024]
Affiliation(s)
- Héloïse Giron
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Amaniel Kefleyesus
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
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14
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Deslarzes P, Jurt J, Larson DW, Blanc C, Hübner M, Grass F. Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice. J Clin Med 2024; 13:801. [PMID: 38337495 PMCID: PMC10856154 DOI: 10.3390/jcm13030801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.
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Affiliation(s)
- Philip Deslarzes
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Jonas Jurt
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - David W. Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA;
| | - Catherine Blanc
- Department of Anesthesiology, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland;
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
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Sakata S, Karim SM, Martinez-Jorge J, Larson DW, Mathis KL, Kelley SR, Rose PS, Dozois EJ. Improving R0 Resection Rates With a Posterior-First, 2-Stage Approach for En Bloc Resection of Locally Advanced Primary and Recurrent Anorectal Cancers Involving the Deep Pelvic Sidewall. Dis Colon Rectum 2024; 67:90-96. [PMID: 38091415 DOI: 10.1097/dcr.0000000000003035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Using standard anterior approaches, consistent R0 resection of locally advanced primary and recurrent rectal and anal cancer involving the deep pelvic sidewall may be unattainable. Therefore, to improve R0 resection rates, we have used a posterior-first, then anterior 2-stage approach to resection of tumors in this location. OBJECTIVE To assess the R0 resection rate and surgical outcomes of the first 10 patients operated on using this approach. DESIGN We conducted a retrospective case series review of our prospectively maintained surgical pathology and tumor registries. SETTING This study was conducted at the Mayo Clinic in Rochester, Minnesota. PATIENTS Ten patients (6 female individuals, median age 53.5 years) with primary or recurrent anal or rectal cancer treated with a posterior-first, then anterior 2-stage approach were identified. MAIN OUTCOME MEASURES The primary outcome measures were the R0 resection rate and surgical outcomes. RESULTS An R0 resection was achieved in all 10 patients. Nine patients developed 1 or more 30-day Clavien-Dindo grade III complications. Nine patients developed gluteal wound complications ranging from superficial wound dehiscence to flap necrosis. During the follow-up period, 4 patients were found to have metastatic disease and 1 patient had local re-recurrence. LIMITATIONS Small cohort with heterogeneous tumors and a short follow-up duration. CONCLUSION A posterior-first, then anterior 2-stage approach has allowed us to achieve consistent R0 resection margins in locally advanced primary and recurrent rectal and anal cancers involving the deep pelvic sidewall. Poor wound healing of the posterior gluteal incision is a common complication. See Video Abstract. MEJORANDO LAS TASAS DE RESECCIN R CON UN ABORDAJE DE DOS ETAPAS PRIMERO POSTERIOR PARA LA RESECCIN EN BLOQUE DE CNCERES ANORRECTALES PRIMARIOS Y RECURRENTES LOCALMENTE AVANZADOS QUE AFECTAN LA PARED LATERAL PLVICA PROFUNDA ANTECEDENTES:Utilizando abordajes anteriores estándares, la resección R0 consistente del cáncer de recto y ano primario y recurrente localmente avanzado involucrando la pared lateral pélvica profunda puede ser inalcanzable. Por lo tanto, para mejorar las tasas de resección R0, hemos empleado un abordaje de 2 etapas primero posterior y luego anterior para la resección de tumores en esta ubicación.OBJETIVO:Este estudio tuvo como objetivo evaluar la tasa de resección R0 y los resultados quirúrgicos de los primeros 10 pacientes operados con este abordaje.DISEÑO:Realizamos una revisión retrospectiva de series de casos de nuestros registros de patología quirúrgica y tumores mantenidos prospectivamente.AJUSTE:Este estudio se realizó en la Clínica Mayo en Rochester, Minnesota, EE. UU.PACIENTES:Se identificaron diez pacientes (6 mujeres, mediana de edad 53.5 años) con cáncer anal o rectal primario o recurrente tratados con un abordaje de dos etapas, primero posterior y luego anterior.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado primarias fueron la tasa de resección R0 y los resultados quirúrgicos.RESULTADOS:Se logró una resección R0 en los 10 pacientes. Nueve pacientes desarrollaron una o más complicaciones de grado III de Clavien-Dindo a los 30 días. Nueve pacientes desarrollaron complicaciones de la herida del glúteo que variaron desde dehiscencia superficial de la herida hasta necrosis del colgajo. Durante el período de seguimiento, se encontró que 4 pacientes tenían enfermedad metastásica y un paciente tuvo recurrencia local.LIMITACIONES:Cohorte pequeño con tumores heterogéneos y corta duración de seguimiento.CONCLUSIÓN:Un abordaje en 2 etapas, primero posterior y luego anterior, nos ha permitido lograr márgenes de resección R0 consistentes en cánceres de recto y anal primarios y recurrentes localmente avanzados que afectan la pared lateral pélvica profunda. La mala cicatrización de la incisión glútea posterior es una complicación común. (Traducción-Dr. Aurian Garcia Gonzalez).
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Affiliation(s)
- Shinichiro Sakata
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - S Mohammed Karim
- Division of Orthopedic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jorys Martinez-Jorge
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter S Rose
- Division of Orthopedic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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West CT, West MA, Mirnezami AH, Drami I, Denys A, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Pape E, van Ramshorst GH, Aalbers AGJ, Abdul AN, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Angenete E, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brown K, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelen W, Chan KKL, Chang GJ, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovic L, Daniels IR, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Denost QD, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Egger E, Eglinton T, Enrique-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Flatmark K, Fleming F, Flor B, Folkesson J, Foskett K, Frizelle FA, Funder J, Gallego MA, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther N, Glover T, Goffredo P, Golda T, Gomez CM, Griffiths B, Gwenaël F, Harris C, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kaufman M, Kazi M, Kelley SR, Keller DS, Kelly ME, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Kusters M, Lago V, Lakkis Z, Lampe B, Langheinrich MC, Larach T, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Mackintosh M, Mann C, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McDermott FD, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Monson JRT, Morton JR, Mullaney TG, Navarro AS, Neeff H, Negoi I, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock A, Pellino G, Peterson AC, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Quyn A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Smith T, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor C, Taylor D, Tejedor P, Tekin A, Tekkis PP, Teras J, Thanapal MR, Thaysen HV, Thorgersen E, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weber K, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Empty pelvis syndrome: PelvEx Collaborative guideline proposal. Br J Surg 2023; 110:1730-1731. [PMID: 37757457 PMCID: PMC10805575 DOI: 10.1093/bjs/znad301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
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Fiorentini G, Zironda A, Calini G, Abdalla S, Nagorney DM, Warner SG, Smoot RL, Behm KT, Shawki SF, Mathis KL, Vierkant RA, Larson DW, Cleary SP. Minimally invasive vs. open approach to the simultaneous treatment of colorectal tumors with synchronous liver metastasis: a single center, propensity-score matched analysis from Mayo clinic. HPB (Oxford) 2023; 25:1337-1344. [PMID: 37626006 DOI: 10.1016/j.hpb.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Open combined resections of colorectal primary tumors and synchronous liver metastases have become common in selected cases. However, evidences favoring a minimally invasive (MIS) approach are still limited. The aim of this study is to evaluate the outcomes of MIS vs. open synchronous liver and colorectal resections. METHODS 384 cases of synchronous colorectal and liver resections performed at one institution were identified during the study period. MIS vs open approach were compared after a propensity score matching; surgical outcomes were analyzed. RESULTS MIS cases featured longer operative time (399 vs 300 min, p < 0.001), fewer blood loss (200 vs 500 ml, p = 0.003), and shorter hospitalization (median LOS 4 vs 6 days, p = 0.001). No difference was observed between the two groups for use of Pringle maneuver (p = 0.083), intraoperative blood transfusion (p = 0.061), achievement of negative colorectal (p = 0.176) and liver margins (p = 1.000), postoperative complications (p = 1.000) and significant (Clavien-Dindo ≥ 3a) complications (p = 0.817), delay of adjuvant therapy due to complications (p = 0.555), 30- and 90-day mortality. CONCLUSION Synchronous colorectal and liver metastases resections via a minimally-invasive approach in high-volume centers with appropriate expertise result in significantly lower blood loss and length of stay despite longer operative time in comparison to open, with no oncological inferiority.
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Affiliation(s)
- Guido Fiorentini
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Andrea Zironda
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Giacomo Calini
- Colorectal Surgery Division, Mayo Clinic, Rochester MN, USA
| | | | - David M Nagorney
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Susanne G Warner
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Rory L Smoot
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Kevin T Behm
- Colorectal Surgery Division, Mayo Clinic, Rochester MN, USA
| | | | | | - Robert A Vierkant
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Colorectal Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Sean P Cleary
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA.
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Calini G, Abdalla S, Abd El Aziz MA, Merchea A, Larson DW, Behm KT. Ileocolic resection for Crohn's disease: robotic intracorporeal compared to laparoscopic extracorporeal anastomosis. J Robot Surg 2023; 17:2157-2166. [PMID: 37264221 DOI: 10.1007/s11701-023-01635-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79 min vs. LECA: 143 ± 52 min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2 days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5 days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amit Merchea
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Phillips KE, Aljobeh A, Benammi S, Abdalla S, Calini G, Shawki SF, Larson DW, Mathis KL. Predictors of ileal pouch failure due to fistulas. Br J Surg 2023; 110:1046-1048. [PMID: 36680369 DOI: 10.1093/bjs/znac446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/14/2022] [Accepted: 11/29/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Kathryn E Phillips
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
- Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ahmad Aljobeh
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
- Mayo Clinic Rochester, Rochester, Minnesota, USA
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Abd El Aziz MA, Abdalla S, Calini G, Saeed H, D'Angelo AL, Behm KT, Shawki S, Mathis KL, Larson DW. Robotic Redo Ileocolonic Resection for Crohn's Disease: A Preliminary Report From a Tertiary Care Center. Dis Colon Rectum 2023; 66:1095-1101. [PMID: 36538722 DOI: 10.1097/dcr.0000000000002380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although the safety of laparoscopic redo ileocolonic resection for Crohn's disease has been described before, the safety of robotic redo ileocolonic resection is still unelucidated. OBJECTIVE This study aimed to share our preliminary experience regarding the safety of robotic redo ileocolonic resection for Crohn's disease. DESIGN Retrospective analysis. SETTING Tertiary care center. PATIENTS All consecutive adult patients who underwent robotic ileocolonic resection for Crohn's disease at our institution between 2014 and 2021 were included. Patients were divided into redo ileocolonic resection and primary ileocolonic resection groups. PRIMARY OUTCOME MEASURES Baseline demographics, preoperative risk factors, and intraoperative details were compared between both groups. The primary outcome was conversion to an open approach, and secondary outcomes were 30-day postoperative complications. RESULTS A total of 98 patients were included. Of them, 18 (18.4%) had a redo ileocolonic resection. Patients who had a redo ileocolonic resection were more likely to have a longer duration of disease, associated anoperineal disease, a higher number of previous lines of medical treatments, received total parental nutrition before the operation for correction of malnutrition, and longer time for adhesiolysis. Patients who had redo ileocolonic resection had a higher risk for conversion to open ileocolonic resection [3 (16.7%) versus 2 (2.5%); p value = 0.04]. There was no statistically significant difference regarding the overall length of stay and the 30-day morbidity between both groups. No 30-day mortality or anastomotic leaks occurred in either group. LIMITATIONS Retrospective nature of the analysis. CONCLUSIONS Robotic redo ileocolonic resection showed similar short-term postoperative outcomes to robotic primary ileocolonic resection for Crohn's disease. However, conversion rates are higher in robotic redo ileocolonic resection yet seem lower than previously published results in laparoscopic surgery. See Video Abstract at http://links.lww.com/DCR/C77 . RESECCIN ILEOCLICA ROBTICA REDO PARA LA ENFERMEDAD DE CROHN INFORME PRELIMINAR DE UN CENTRO DE ATENCIN TERCIARIA ANTECEDENTES:Si bien la seguridad de la resección ileocolónica laparoscópica para la enfermedad de Crohn se ha descrito antes, la seguridad de la resección ileocolónica robótica aún no se ha dilucidado.OBJETIVO:Este estudio tuvo como objetivo compartir nuestra experiencia preliminar con respecto a la seguridad de la resección ileocolónica robótica para la enfermedad de Crohn.DISEÑO:Análisis retrospectivo.AJUSTE:Centro de atención terciaria.PACIENTES:Se incluyeron todos los pacientes adultos consecutivos que se sometieron a resección ileocolónica robótica por enfermedad de Crohn en nuestra institución entre 2014 y 2021. Los pacientes se dividieron en grupos de resección ileocolónica reconfeccionada y resección ileocolónica primaria.MEDIDAS DE RESULTADO:Se compararon los datos demográficos iniciales, los factores de riesgo preoperatorios y los detalles intraoperatorios entre ambos grupos. El resultado primario fue la conversión a abierto y los resultados secundarios fueron las complicaciones posoperatorias a los treinta días.RESULTADOS:Se incluyeron un total de 98 pacientes. De ellos, 18 (18,4%) tuvieron resección ileocolónica. Los pacientes que se sometieron a una nueva resección ileocolónica tenían más probabilidades de tener una mayor duración de la enfermedad, enfermedad anoperineal asociada, un mayor número de líneas previas de tratamientos médicos, más probabilidades de haber recibido nutrición parental total antes de la operación para la corrección de la desnutrición y más tiempo tiempo de adhesiolisis. Los pacientes que se sometieron a una nueva resección ileocolónica tuvieron un mayor riesgo de conversión a cirugía abierta [3 (16,7 %) frente a 2 (2,5 %); valor p 0,04]. No hubo diferencia estadísticamente significativa con respecto a la duración total de la estancia y la morbilidad a los treinta días entre ambos grupos. No hubo mortalidad a los treinta días ni fugas anastomóticas en ninguno de los grupos.LIMITACIONES:Naturaleza retrospectiva del análisis.CONCLUSIÓN:La resección ileocolónica robótica mostró resultados postoperatorios a corto plazo similares a la resección ileocolónica primaria robótica para la enfermedad de Crohn. Sin embargo, las tasas de conversión son más altas en la resección ileocolónica robótica, pero parecen más bajas que los resultados publicados previamente en la cirugía laparoscópica. Consulte Video Resumen en http://links.lww.com/DCR/C77 . (Traducción-Dr Yolanda Colorado ).
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Calini G, Abdalla S, Aziz MAAE, Behm KT, Shawki SF, Mathis KL, Larson DW. Incisional hernia rates between intracorporeal and extracorporeal anastomosis in minimally invasive ileocolic resection for Crohn's disease. Langenbecks Arch Surg 2023; 408:251. [PMID: 37382678 DOI: 10.1007/s00423-023-02976-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/10/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE One-third of patients with Crohn's disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). METHODS This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center. RESULTS Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p = 0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p = 0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3 ± 2.5 vs. ECA-M: 4.1 ± 2.4 days; p = 0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p = 0.064] and readmission rates [7(11.9) vs. 18(9.5); p = 0.59]. CONCLUSION Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Sherief F Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Calini G, Abdalla S, Abd El Aziz MA, Benammi S, Merchea A, Behm KT, Mathis KL, Larson DW. Open approach for ileocolic resection in Crohn's disease in the era of minimally invasive surgery: indications and perioperative outcomes in a referral center. Updates Surg 2023:10.1007/s13304-023-01528-1. [PMID: 37149508 DOI: 10.1007/s13304-023-01528-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 04/29/2023] [Indexed: 05/08/2023]
Abstract
Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in Crohn's disease (CD), and it is safe and feasible, even with severe penetrating CD or redo surgery. While MIS indications are continually broadening, challenging CD cases might still require an open approach. This study aimed to report rate and indications for an upfront open approach in ileocolic resection for CD. Comprehensive perioperative data for all consecutive patients undergoing ileocolic resection for CD between 2014 and 2021 in a high-volume referral center for CD and MIS, were collected retrospectively. Indications for an upfront open approach were reviewed separately by two authors according to the preoperative visit. Among 319 ileocolic resections for CD, 45 (14%) were open and 274 (86%) MIS. Two or more of the below indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p < 0.0001). Indications for upfront open approach were severe penetrating disease (58%), adhesions at previous surgery (47%), history of abdominal sepsis (33%), multifocal and extensive disease (24%), abdominal wall involvement (22%), concomitant open procedures (9%), small bowel dilatation (9%), and anesthesiologic contraindications (4%). MIS was never performed in a patient with abdominal wall involvement, concomitant open procedure, and anesthesiologic contraindication to MIS. This study can help guide patients, physicians, and surgeons. An abdominal wall involvement or the presence of two of the above indications predicts a high surgical complexity and may be considered as a no-go for the MIS approach. These criteria should prompt surgeons to strongly consider an upfront open approach to optimize the perioperative planning and care of these complex patients.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Sarah Benammi
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Calini G, Abd El Aziz MA, Paolini L, Abdalla S, Rottoli M, Mari G, Larson DW. Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management. Clin Exp Gastroenterol 2023; 16:29-43. [PMID: 37013200 PMCID: PMC10066719 DOI: 10.2147/ceg.s340929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/18/2023] [Indexed: 04/05/2023] Open
Abstract
Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle - physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables - is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Medical Area, University of Udine, Udine, Italy
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Internal Medicine Department, MercyOne North Iowa, Mason City, IA, USA
| | - Lucia Paolini
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Oncologic and Digestive Surgery, Le Kremlin-Bicêtre University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Matteo Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giulio Mari
- Department of Laparoscopic and Oncological General Surgery, ASST Brianza, Desio Hospital, Desio, Italy
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Calini G, Abdalla S, Aziz MAAE, Behm KT, Shawki SF, Mathis KL, Larson DW. Incisional Hernia rates between Intracorporeal and Extracorporeal Anastomosis in Minimally Invasive Ileocolic Resection for Crohn's disease.. [DOI: 10.21203/rs.3.rs-2591968/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Abstract
Purpose: One-third of patients with Crohn’s disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M).
Methods: This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center.
Results: Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p=0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p =0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3±2.5 vs. ECA-M: 4.1±2.4 days; p=0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p=0.064] and readmission rates [7(11.9) vs. 18(9.5); p=0.59].
Conclusion: Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.
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Fahy MR, Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angeles MA, Angenete E, Antoniou A, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Beynon J, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelan W, Chan KKL, Chang GJ, Chang M, Chew MH, Chok AY, Chong P, Clouston H, Codd M, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovich L, Daniels IR, Davies M, Delaney CP, de Wilt JHW, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Eglinton T, Enriquez-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fearnhead NS, Ferron G, Flatmark K, Fleming FJ, Flor B, Folkesson J, Frizelle FA, Funder J, Gallego MA, Gargiulo M, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther DN, Glyn T, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kazi M, Kelley SR, Keller DS, Ketelaers SHJ, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kristensen HØ, Kroon HM, Kumar S, Kusters M, Lago V, Lampe B, Lakkis Z, Larach JT, Larkin JO, Larsen SG, Larson DW, Law WL, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Maciel J, Manfredelli S, Mann C, Mantyh C, Mathis KL, Marques CFS, Martinez A, Martling A, Mehigan BJ, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, Mikalauskas S, McArthur DR, McCormick JJ, McCormick P, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Navarro AS, Negoi I, Neto JWM, Ng JL, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, Nugent T, Oliver A, O’Dwyer ST, O’Sullivan NJ, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock O, Pellino G, Peterson AC, Pinson J, Poggioli G, Proud D, Quinn M, Quyn A, Rajendran N, Radwan RW, Rajendran N, Rao C, Rasheed S, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Selvasekar C, Shaikh I, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Sorrentino L, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Spasojevic M, Sumrien H, Sutton PA, Swartking T, Takala H, Tan EJ, Taylor C, Tekin A, Tekkis PP, Teras J, Thaysen HV, Thurairaja R, Thorgersen EB, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Valente M, van Ramshorst GH, van Zoggel D, Vasquez-Jimenez W, Vather R, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Urrejola G, Wakeman C, Warrier SK, Wasmuth HH, Waters PS, Weber K, Weiser MR, Wheeler JMD, Wild J, Williams A, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline. Br J Surg 2022; 109:1251-1263. [PMID: 36170347 DOI: 10.1093/bjs/znac317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/18/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022]
Abstract
This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.
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Ruan X, Fu S, Storlie CB, Mathis KL, Larson DW, Liu H. Real-time risk prediction of colorectal surgery-related post-surgical complications using GRU-D model. J Biomed Inform 2022; 135:104202. [PMID: 36162805 DOI: 10.1016/j.jbi.2022.104202] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/21/2022] [Accepted: 09/04/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Post-surgical complications (PSCs) have been an increasing concern for hospitals in light of Medicare penalties for 30-day readmissions. PSCs have become a target for quality improvement and benchmark for the healthcare system. Over half (60 %) of the deep or organ space surgical site infections are discovered after discharge, leading to a readmission. There has thus been a push to develop risk prediction models for targeted preventive interventions for PSCs. OBJECTIVE We experiment several Gated Recurrent Unit with Decay (GRU-D) based deep learning architectures with various feature sampling schemes in predicting the risk of colorectal PSCs and compare with atemporal logistic regression models (logit). METHOD We used electronic health record (EHR) data of 3,535 colorectal surgical patients involved in the national surgical quality improvement program (NSQIP) between 2006 and 2018. Single layer, stacked layer, and multimodal GRU-D models with sigmoid activation were used to develop risk prediction models. Area Under the Receiver Operating Characteristic curve (AUROC) was calculated by comparing predicted probability of developing complications versus truly observed PSCs (NSQIP adjudicated) within 30 days after surgery. We set up cross-validation and an independent held-out dataset for testing model performance consistency. RESULTS AND CONCLUSION The primary contribution of our study is the formulation of a novel real-time PSC risk prediction task using GRU-D with demonstrated clinical utility. GRU-D outperforms the logit model in predicting wound and organ space infection and shows improved performance as additional data points become available. Logit model outperforms GRU-D before surgery for superficial infection and bleeding. For the same sampling scheme, there is no obvious advantage of complex architectures (stacked, multimodal) over single layer GRU-D. Obtaining more data points closer to the occurrence of PSCs is more important than using a more frequent sampling scheme in training GRU-D models. The fourth predicted risk quartile by single layer GRU-D contains 63 %, 59 %, and 66 % organ space infection cases, at 4 h before, 72 h after, and 168 h after surgery, respectively, suggesting its potential application as a bedside risk assessment tool.
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Affiliation(s)
- Xiaoyang Ruan
- Department of Artificial Intelligence & Informatics, Mayo Clinic, Rochester, MN, United States
| | - Sunyang Fu
- Department of Artificial Intelligence & Informatics, Mayo Clinic, Rochester, MN, United States
| | - Curtis B Storlie
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States
| | - Kellie L Mathis
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
| | - David W Larson
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
| | - Hongfang Liu
- Department of Artificial Intelligence & Informatics, Mayo Clinic, Rochester, MN, United States.
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Abd El Aziz MA, Abdalla S, Calini G, Saeed H, Stocchi L, Merchea A, Colibaseanu DT, Shawki S, Larson DW. Postoperative Safety Profile of Minimally Invasive Ileocolonic Resections for Crohn's Disease in the Era of Biologic Therapy. J Crohns Colitis 2022; 16:1079-1088. [PMID: 35045164 DOI: 10.1093/ecco-jcc/jjac012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 12/02/2021] [Accepted: 01/14/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND There is controversy regarding the postoperative outcomes in Crohn's disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy. METHODS All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon's discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications. RESULTS A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease. CONCLUSIONS This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn's disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn's disease. Further studies with larger sample sizes are needed to confirm results.
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Affiliation(s)
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hamadelneel Saeed
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Luca Stocchi
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Sherief Shawki
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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McKenna NP, Glasgow AE, Shariq OA, Larson DW, Ghanem OM, McKenzie TJ, Habermann EB. Challenging Surgical Dogma: Are Routine Postoperative Day 1 Labs Necessary after Bariatric Operations? Surg Obes Relat Dis 2022; 18:1261-1268. [DOI: 10.1016/j.soard.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/16/2022] [Accepted: 07/13/2022] [Indexed: 11/25/2022]
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Abdalla S, Abd El Aziz MA, Calini G, Saeed H, Merchea A, Shawki S, Behm KT, Larson DW. Perioperative outcomes of minimally invasive ileocolic resection for complicated Crohn disease: Results from a referral center retrospective cohort. Surgery 2022; 172:522-529. [PMID: 35337682 DOI: 10.1016/j.surg.2022.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Minimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease. METHODS A retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group). RESULTS Among the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P = .004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P = .002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P = .463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P = .463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P = .231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P = .309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P = .188). CONCLUSION Minimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results.
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Affiliation(s)
- Solafah Abdalla
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | | - Giacomo Calini
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL
| | - Sherief Shawki
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
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Achilli P, Magistro C, Abd El Aziz MA, Calini G, Bertoglio CL, Ferrari G, Mari G, Maggioni D, Peros G, Tamburello S, Coppola E, Spinelli A, Grass F, Martin D, Hahnloser D, Salvatori A, De Simoni S, Sheedy SP, Fletcher JG, Larson DW. Modest agreement between magnetic resonance and pathological tumor regression after neoadjuvant therapy for rectal cancer in the real world. Int J Cancer 2022; 151:120-127. [PMID: 35191540 DOI: 10.1002/ijc.33975] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/12/2022]
Abstract
Magnetic Resonance Imaging (MRI) is routinely used for preoperative tumor staging and to assess response to therapy in rectal cancer patients. The aim of this study was to evaluate the accuracy of MRI based restaging after neoadjuvant CRT in predicting pathologic response. This multicenter cohort study included adult patients with histologically confirmed locally advanced rectal adenocarcinoma treated with neoadjuvant CRT followed by curative intent elective surgery between January 2014 and December 2019 at four academic high-volume institutions. Magnetic resonance tumor regression grade (mrTRG) and pathologic tumor regression grade (pTRG) were reviewed and compared for all the patients. The agreement between radiologist and pathologist was assessed with the weighted k test. Risk factors for poor agreement were investigated using logistic regression. A total of 309 patients were included. Modest agreement was found between mrTRG and pTRG when regression was classified according to standard five-tier systems (k=0.386). When only two categories were considered for each regression system, (pTRG 0-3 vs. pTRG 4; mrTRG 2-5 vs. mrTRG 1) an accuracy of 78% (IC 95% 0.73-0.83) was found between radiologic and pathologic assessment with a k value of 0.185.The logistic regression model revealed that "T3 greater than 5mm extent" was the only variable significantly impacting on disagreement (OR 0.33, 95% CI 0.15-0.68, p=0.0034). Modest agreement exhists between mrTRG and pTRG. The chances of appropriate assessment of the regression grade after neoadjuvant CRT appear to be higher in case of a T3 tumor with at least 5mm extension in the mesorectal fat at the pre-treatment MRI. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Pietro Achilli
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of mini-invasive surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Carmelo Magistro
- Department of mini-invasive surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Camillo L Bertoglio
- Department of mini-invasive surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanni Ferrari
- Department of mini-invasive surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giulio Mari
- Department of surgery, Desio Hospital, Desio, Italy
| | | | - Georgios Peros
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milan, Italy
| | - Sara Tamburello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milan, Italy
| | - Elisabetta Coppola
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano - Milan, Italy
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - David Martin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Andrea Salvatori
- Branch of Medical Statistics, Biometry, and Epidemiology "G. A. Maccacaro", Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Silvia De Simoni
- Department of Radiology, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Joel G Fletcher
- Mayo Clinic Department of Radiology, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Pedrazzani C, Turri G, Park SY, Hida K, Fukui Y, Crippa J, Ferrari G, Origi M, Spolverato G, Zuin M, Bae SU, Baek SK, Costanzi A, Maggioni D, Son GM, Scala A, Rockall T, Larson DW, Guglielmi A, Choi GS. Laparoscopic versus open surgery for left flexure colon cancer: A propensity score matched analysis from an international cohort. Colorectal Dis 2022; 24:177-187. [PMID: 34706130 PMCID: PMC9299165 DOI: 10.1111/codi.15962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/20/2021] [Accepted: 10/22/2021] [Indexed: 12/20/2022]
Abstract
AIM Surgical treatment of splenic flexure cancer (SFC) still presents some debated issues, including the role of laparoscopic surgery. The literature is based on small single-centre series, while randomized controlled studies comparing open and laparoscopic treatment for colon cancer exclude SFC. This study aimed to determine the role of laparoscopic surgery in the treatment of SFC, comparing short- and long-term outcomes with open surgery. METHOD This was an international multicentre retrospective cohort study that analysed patients from 10 tertiary referral centres. From a cohort of 641 cases, 484 patients with Stage I-III SFC submitted to elective surgery with curative intent were selected. After 1:1 propensity score matching, 130 patients in the laparoscopic group (LapGroup) were compared with 130 patients in the open surgery group (OpenGroup). RESULTS After propensity score matching, the two groups were comparable for demographic and clinical parameters. OpenGroup presented a higher incidence of overall (P = 0.02) and surgery-related complications (P = 0.05) but a similar rate of severe complications (P = 0.75). Length of stay was notably shorter in the LapGroup (P = 0.001). Overall (P = 0.793) as well as cancer-specific survival (P = 0.63) did not differ between the two groups. CONCLUSIONS Elective laparoscopic surgery for Stage I-III SFC is feasible and associated with improved short-term postoperative outcomes compared to open surgery. Moreover, laparoscopic surgery appears to provide excellent long-term cancer outcomes.
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Affiliation(s)
- Corrado Pedrazzani
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynecology and PediatricsUniversity of VeronaVeronaItaly
| | - Giulia Turri
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynecology and PediatricsUniversity of VeronaVeronaItaly
| | - Soo Yeun Park
- Colorectal Cancer CentreKyungpook National University Medical CentreSchool of MedicineKyungpook National UniversityDaeguKorea
| | - Koya Hida
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Yudai Fukui
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Jacopo Crippa
- Division of Colon and Rectal SurgeryDepartment of SurgeryMayo ClinicRochesterMinnesotaUSA
| | - Giovanni Ferrari
- Department of General SurgeryNiguarda HospitalASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Matteo Origi
- Department of General SurgeryNiguarda HospitalASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Gaya Spolverato
- First Surgical Clinic SectionDepartment of Surgery, Oncology, and GastroenterologyUniversity of PadovaPadovaItaly
| | - Matteo Zuin
- First Surgical Clinic SectionDepartment of Surgery, Oncology, and GastroenterologyUniversity of PadovaPadovaItaly
| | - Sung Uk Bae
- Division of Colorectal SurgeryDepartment of SurgerySchool of MedicineKeimyung University and Dongsan Medical CentreDaeguKorea
| | - Seong Kyu Baek
- Division of Colorectal SurgeryDepartment of SurgerySchool of MedicineKeimyung University and Dongsan Medical CentreDaeguKorea
| | | | | | - Gyung Mo Son
- Department of SurgeryPusan National University Yangsan HospitalSchool of MedicinePusan National UniversityYangsanKorea
| | - Andrea Scala
- Department of Colorectal and Minimal Access SurgeryRoyal Surrey NHS Foundation TrustGuildfordUK
| | - Timothy Rockall
- Department of Colorectal and Minimal Access SurgeryRoyal Surrey NHS Foundation TrustGuildfordUK
| | - David W. Larson
- Division of Colon and Rectal SurgeryDepartment of SurgeryMayo ClinicRochesterMinnesotaUSA
| | - Alfredo Guglielmi
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynecology and PediatricsUniversity of VeronaVeronaItaly
| | - Gyu Seog Choi
- Colorectal Cancer CentreKyungpook National University Medical CentreSchool of MedicineKyungpook National UniversityDaeguKorea
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Calini G, Abd El Aziz MA, Solafah A, Saeed HA, Lovely JK, D'Angelo AL, Larson DW, Kelley SR, Colibaseanu DT, Behm KT. Laparoscopic transversus abdominis plane block versus intrathecal analgesia in robotic colorectal surgery. Br J Surg 2021; 108:e369-e370. [PMID: 34459868 DOI: 10.1093/bjs/znab294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/21/2021] [Indexed: 11/14/2022]
Affiliation(s)
- G Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - M A Abd El Aziz
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - A Solafah
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - H A Saeed
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - J K Lovely
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | - A-L D'Angelo
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - S R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - D T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - K T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Grass F, Hübner M, Behm KT, Mathis KL, Hahnloser D, Day CN, Harmsen WS, Demartines N, Larson DW. Development and validation of a prediction score for safe outpatient colorectal resections. Surgery 2021; 171:336-341. [PMID: 34503851 DOI: 10.1016/j.surg.2021.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Avoiding unnecessary inpatient stay may decrease hospital-acquired complications and costs while increasing patient satisfaction. This study aimed to develop and validate a score to identify patients eligible for safe same-day discharge after colorectal resections. METHODS This bi-institutional retrospective cohort study included consecutive patients undergoing elective colon and rectal resections (2011-2018) for benign and malignant indications. Two multivariable logistic models were developed based on demographic and surgical risk factors to predict a combined endpoint (ileus, anastomotic leak, intra-abdominal abscess, and readmission). Development and validation datasets were randomly sampled from the entire cohort. Areas under the receiver operating characteristic curves (AUC) were evaluated, and Hosmer-Lemeshow goodness-of-fit tests were used to assess validation model fit. RESULTS Of 5,389 patients, 1,182 (21.9%) experienced at least one complication of the combined endpoint. Male gender, open surgery, ASA ≥3, wound class ≥3, ileostomy, surgical duration >3 hours, and perioperative IV fluids >3 L all had significantly greater odds of the combined endpoint in the parsimonious multivariable model (all P < .05). The reduced model considering only the 4 variables with the highest OR (>1.5) contained open surgery, ASA ≥3, wound class ≥3, and surgical duration ≥3 hours as predictors (all P < .05, AUC of 0.65; 95% CI 0.63, 0.68). Both the parsimonious model and the reduced model demonstrated no lack of fit in the validation cohort. CONCLUSION The suggested score composed of preand intraoperative items may help physicians decide on patients' same-day discharge after colorectal resection.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN; Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - Courtney N Day
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
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Calini G, Abdalla S, Abd El Aziz MA, Saeed HA, D'Angelo ALD, Behm KT, Shawki S, Mathis KL, Larson DW. Intracorporeal versus extracorporeal anastomosis for robotic ileocolic resection in Crohn's disease. J Robot Surg 2021; 16:601-609. [PMID: 34313950 DOI: 10.1007/s11701-021-01283-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022]
Abstract
To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn's Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p < 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Hamedelneel A Saeed
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Anne-Lise D D'Angelo
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Sherief Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Chen D, Jiang J, Fu S, Demuth G, Liu S, Schaeferle GM, Wilson PM, Habermann E, Larson DW, Storlie C, Liu H. Early Detection of Post-Surgical Complications using Time-series Electronic Health Records. AMIA Jt Summits Transl Sci Proc 2021; 2021:152-160. [PMID: 34457129 PMCID: PMC8378618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Models predicting health complications are increasingly attempting to reflect the temporally changing nature of patient status. However, both the practice of medicine and electronic health records (EHR) have yet to provide a true longitudinal representation of a patient's medical history as relevant data is often asynchronous and highly missing. To match the stringent requirements of many static time models, time-series data has to be truncated, and missing values in samples have to be filled heuristically. However, these data preprocessing procedures may unconsciously misinterpret real-world data, and eventually lead into failure in practice. In this work, we proposed an augmented gated recurrent unit (GRU), which formulate both missingness and timeline signals into GRU cells. Real patient data of post-operative bleeding (POB) after Colon and Rectal Surgery (CRS) was collected from Mayo Clinic EHR system to evaluate the effectiveness of proposed model. Conventional models were also trained with imputed dataset, in which event missingness or asynchronicity were approximated. The performance of proposed model surpassed current state-of-the-art methods in this POB detection task, indicating our model could be more eligible to handle EHR datasets.
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Affiliation(s)
| | | | | | | | | | | | | | | | - David W Larson
- Department of Colorectal Surgery, Mayo Clinic, Rochester, MN, USA
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Calini G, Abd El Aziz MA, Abdalla S, Saeed HA, Lovely JK, D'Angelo ALD, Behm KT, Colibaseanu DT, Mathis KL, Larson DW. Patient colon and rectal operative outcomes when treated with immune checkpoint inhibitors. Eur J Surg Oncol 2021; 47:2436-2440. [PMID: 33883088 DOI: 10.1016/j.ejso.2021.03.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022] Open
Abstract
There is limited data about the safety of colorectal surgery after immune checkpoint inhibitors (ICI). We aimed to share our experience about postoperative outcomes of colorectal surgery for patients treated with ICI. Overall, 31 patients were identified, 22 (71%) underwent elective and nine (29%) underwent emergent/urgent surgery. The 30-day Clavien Dindo class ≥ III complication rates were 27.3% (n = 6) for elective and 55.5% (n = 5) for emergent/urgent cases. Four patients underwent emergency surgery for immune-related colonic perforation and developed postoperative septic shock; two died. Considering patients' comorbidities, cancer stage, and surgical complexity, elective colorectal surgery after ICI seems relatively safe. However, emergent/urgent colorectal surgery was associated with high postoperative morbidity. Indeed, colonic perforation in the setting of ICI treatment has a significant risk of postoperative mortality. Therefore, for patients on ICI with any acute abdominal symptoms, surgical consult should be involved, and colon perforation should be ruled out.
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Affiliation(s)
- Giacomo Calini
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Solafah Abdalla
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hamedelneel A Saeed
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jenna K Lovely
- Department of Pharmacy Services, Mayo Clinic, Rochester, MN, USA
| | - Anne-Lise D D'Angelo
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kevin T Behm
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dorin T Colibaseanu
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kellie L Mathis
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Grass F, Hübner M, Crippa J, Lovely JK, Huebner M, Larson DW. Temporal patterns of hospital readmissions according to disease category for patients after elective colorectal surgery. J Eval Clin Pract 2021; 27:218-222. [PMID: 32212421 DOI: 10.1111/jep.13387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Abstract
RATIONALE The aim of this study was to identify temporal readmission patterns according to baseline disease categories to provide opportunities for targeted interventions. METHODS Retrospective analysis of consecutive adult (≥18 years) patients who underwent elective colorectal resections (2011-2017) at Mayo Clinic Rochester, MN. A prospective administrative database including patient demographics, procedure characteristics, discharge information and specifics on 30-day readmissions (to index facility) including timing and reasons was utilized. The ICD-9 codes were regrouped into the main pathologies Cancer, Crohn's disease (CD)/chronic ulcerative colitis (CUC), and diverticular disease. RESULTS In total, 521 (7.2%) out of 7245 patients undergoing inpatient colorectal surgery were readmitted. In all increments of time from discharge (0-2 days: 31.3% of all readmissions, 3-7 days: 32.4% of all readmissions, 8-14 days: 18% of all readmissions, and 15-30 days: 18.3% of all readmissions), reasons for readmission differed significantly (all P < 0.001). Across all disease categories, early readmissions (within 2 days of discharge) were most likely due to ileus/obstruction (53.4% of early readmissions), whereas with 42.5%, infection was the most common cause for late readmissions (>7 days). Patients with home discharge were more likely to be readmitted earlier within the 30-day observation period (P = 0.099), whereas patients with a longer length of index hospital stay (>7 days) were readmitted later (P = 0.080). CONCLUSIONS Reasons for readmission appear to be universal across different disease categories. Targeted educational and collaborative measures may help to mitigate the burden of hospital readmissions to index facilities.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jenna K Lovely
- Hospital Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Marianne Huebner
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Larson DW, Abd El Aziz MA, Perry W, D'Angelo AL, Behm KT, Mathis KL, Grass F. Additional Value of Preoperative Albumin for Surgical Risk Stratification among Colorectal Cancer Patients. Ann Nutr Metab 2021; 76:422-430. [PMID: 33721871 DOI: 10.1159/000514058] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND BMI ≤18.5 kg/m2 and preoperative weight loss may lead to inaccurate assessment of nutritional status, given the increasing prevalence of obesity. The aim of this study was to assess whether clinical evaluation of malnutrition based on these parameters is sufficient to predict complications after colorectal cancer surgery. MATERIALS AND METHODS The American College of Surgeons-National Quality Improvement Program database was queried from 2005 to 2018. Patients undergoing elective colorectal cancer surgery were divided into 4 groups: (1) albumin <3.1 g/dL within 21 days of surgery, (2) European Society for Clinical Nutrition and Metabolism (ESPEN) 2 clinical parameters for malnutrition (≥10% loss of weight/6 months plus [BMI <20 kg/m2 if age <70 years OR BMI <22 kg/m2 if age ≥70 years]), (3) both aforementioned criteria, and (4) none of aforementioned criteria. RESULTS Of 82,280 patients, 5,932 (7.2%) had hypoalbuminemia <3.1 g/dL, 764 (0.9%) fulfilled clinical ESPEN 2 parameters, and 338 (0.4%) met both criteria. After adjusting for baseline confounders, patients in the hypoalbuminemia group had a higher risk of overall complications (odds ratio [OR] 1.92, p < 0.05 vs. OR 1.18 in the ESPEN 2 group, p < 0.05), major complications (OR 1.98, p < 0.05 vs. OR 1.20, p < 0.05), surgical complications (OR 1.77, 95% p < 0.05 vs. OR 1.1, p > 0.05), medical complications (OR 1.73, p < 0.05 vs. OR 1.16, p > 0.05), surgical site infection (OR 1.32, p < 0.05 vs. OR 0.86, p > 0.05), and prolonged hospitalization (OR 1.79, p < 0.05 vs. OR 1.22, p < 0.05). Patients who met both criteria were at highest risk. CONCLUSIONS Preoperative measurement of serum albumin appears to be essential to identify patients at risk for complications after colorectal cancer surgery. Clinical evaluation through BMI and weight loss alone may underestimate surgery-associated risks in the USA.
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Affiliation(s)
- David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William Perry
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anne-Lise D'Angelo
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland,
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Crippa J, Grass F, Achilli P, Behm KT, Mathis KL, Day CN, Harmsen WS, Mari GM, Larson DW. Surgical Approach to Transverse Colon Cancer: Analysis of Current Practice and Oncological Outcomes Using the National Cancer Database. Dis Colon Rectum 2021; 64:284-292. [PMID: 33555708 DOI: 10.1097/dcr.0000000000001887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgical treatment for transverse colon cancer involves either extended colectomy or segmental resection, depending on the location of the tumor and surgeon perspective. However, the oncological safety of segmental resection has not yet been established in large cohort studies. OBJECTIVE This study aims to compare segmental resection versus extended colectomy for transverse colon cancer in terms of oncological outcomes. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted using a nationwide cohort. PATIENTS A total of 66,062 patients who underwent colectomy with curative intent for transverse stage I to III adenocarcinoma were identified in the National Cancer Database (2004-2015). MAIN OUTCOME MEASURES Patients were divided in 2 groups based on the type of surgery received (extended versus segmental resection). The primary outcome was overall survival. Secondary outcomes were 30- and 90-day mortality, length of hospital stay, and readmission rate within 30 days of surgical discharge. RESULTS Extended colectomy was performed in 44,417 (67.2%) patients, whereas 21,645 (32.8%) patients underwent segmental resection. Extended colectomy was associated with lower survival at multivariate analysis (HR, 1.07; 95% CI, 1.04-1.10; p < 0.001). The subgroup analysis showed that extended resection was independently associated with poorer survival in mid transverse colon cancers (HR, 1.08; 95% CI, 1.04-1.12; p < 0.001) and in stage III tumors (HR, 1.11; 95% CI, 1.04-1.18; p < 0.001). The number of at least 12 harvested lymph nodes was an independent predictor of improved survival in both overall and subgroup analyses. LIMITATIONS This study was limited by its retrospective design. CONCLUSION Extended colectomy was not associated with a survival advantage compared with segmental resection. On the contrary, extended colectomy was associated with slightly poorer survival in mid transverse cancers and locally advanced tumors. Segmental resection was found to be safe when appropriate margins and adequate lymph node harvest were achieved. See Video Abstract at http://links.lww.com/DCR/B454. ABORDAJE QUIRRGICO DEL CNCER DE COLON TRANSVERSO ANLISIS DE LA PRCTICA ACTUAL Y LOS RESULTADOS ONCOLGICOS UTILIZANDO LA BASE DE DATOS NACIONAL DE CNCER ANTECEDENTES:El tratamiento quirúrgico para el cáncer de colon transverso implica colectomía extendida o resección segmentaria, según la ubicación del tumor y la perspectiva del cirujano. Sin embargo, la seguridad oncológica de la resección segmentaria aún no se ha establecido en estudios de cohortes grandes.OBJETIVO:Este estudio tiene como objetivo comparar la resección segmentaria versus la colectomía extendida para el cáncer de colon transverso en términos de resultados oncológicos.DISEÑO:Este fue un estudio de cohorte retrospectivo.ESCENARIO:Este estudio se realizó utilizando una cohorte a nivel nacional.PACIENTES:Un total de 66,062 pacientes que se sometieron a colectomía con intención curativa por adenocarcinoma de colon transverso en estadio I-III fueron identificados en la Base de Datos Nacional del Cáncer (2004-2015).PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes se dividieron en dos grupos según el tipo de cirugía recibida (resección extendida versus resección segmentaria). El resultado primario fue la supervivencia global. Los resultados secundarios fueron la mortalidad a los 30 y 90 días, la duración de la estancia hospitalaria y la tasa de reingreso dentro de los 30 días posteriores al alta quirúrgica.RESULTADOS:Se realizó colectomía extendida en 44,417 (67.2%) casos, mientras que 21,645 (32.8%) pacientes fueron sometidos a resección segmentaria. La colectomía extendida se asoció con una menor supervivencia en el análisis multivariado (HR 1.07 IC 95% 1.04-1.10; p <0.001). El análisis de subgrupos mostró que la resección extendida se asoció de forma independiente con una menor supervivencia en los cánceres de colon transverso medio (HR 1.08 IC 95% 1.04-1.12; p <0.001) y en tumores en estadio III (HR 1.11 IC 95% 1.04-1.18; p <0.001). Un número de al menos 12 ganglios linfáticos cosechados fue un predictor independiente de una mejor supervivencia en los análisis general y de subgrupos.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓN:La colectomía extendida no se asoció con una ventaja de supervivencia en comparación con la resección segmentaria. Por el contrario, la colectomía extendida se asoció con una supervivencia levemente menor en cánceres de colon transverso medio y tumores localmente avanzados. Se encontró que la resección segmentaria es segura cuando se logran los márgenes apropiados y la cosecha adecuada de ganglios linfáticos. Consulte Video Resumen en http://links.lww.com/DCR/B454.
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Affiliation(s)
- Jacopo Crippa
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Fabian Grass
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Pietro Achilli
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin T Behm
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Courtney N Day
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota
| | - Giulio M Mari
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Larson DW, Abd El Aziz MA, Perry W, Behm KT, Shawki S, Mandrekar J, Mathis KL, Grass F. Surgical Resection for Crohn's and Cancer: A Comparison of Disease-Specific Risk Factors and Outcomes. Dig Surg 2021; 38:120-127. [PMID: 33503622 DOI: 10.1159/000511909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES The goal of this study was to compare disease-specific risk factors and 30-day outcomes between patients with Crohn's disease (CD) and colon cancer (CC) undergoing right-sided surgical resection. METHODS The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP®) was interrogated to extract all patients ≥18 years undergoing elective right-sided resection for CD versus CC. Independent risk factors for surgical complications were identified through multivariable logistic regression for both groups. In a second step, surgical and medical 30-day morbidity was compared after risk adjustment. RESULTS The cohort consisted of 17,516 patients, of which 2,899 (16.6%) underwent surgery for CD versus 14,617 (83.4%) for CC. Independent risk factors for surgical complications in patients with CD were male gender, African American race, ASA score (III or IV), active smoking, prolonged surgery, and preoperative anemia. Independent risk factors for surgical complications in the cancer group were age ≥70 years, male gender, ASA score (III or IV), respiratory and cardiovascular comorbidities, and preoperative hypoalbuminemia (<3.5 g/dL). After risk adjustment, surgical complications (OR 1.25, p = 0.002), sepsis (OR 1.64, p = 0.012), and unplanned readmissions (OR 1.39, p = 0.004) were more common in patients with CD. Thirty-day mortality was higher in cancer patients (1.1 vs. 0.1%, p < 0.0001). CONCLUSIONS Patients with Crohn's disease were more prone to surgical complications and postoperative sepsis compared to the cancer group undergoing the same procedure. Careful evaluation and correction of disease-specific modifiable risk factors of patients with CD and CC, respectively, are important.
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Affiliation(s)
- David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William Perry
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sherief Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jay Mandrekar
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland,
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Grass F, Merchea A, Mathis KL, Mishra N, Heien H, Sangaralingham LR, Larson DW. Cost drivers of locally advanced rectal cancer treatment-An analysis of a leading healthcare insurer. J Surg Oncol 2021; 123:1023-1029. [PMID: 33497477 DOI: 10.1002/jso.26390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/01/2021] [Accepted: 01/10/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients. METHODS Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database. RESULTS In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average $183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients. CONCLUSION Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Switzerland
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nitin Mishra
- Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Herbert Heien
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Pedrazzani C, Turri G, Park SY, Hida K, Fukui Y, Crippa J, Ferrari G, Origi M, Spolverato G, Zuin M, Bae SU, Baek SK, Costanzi A, Maggioni D, Son GM, Scala A, Rockall T, Guglielmi A, Choi GS, Larson DW. Clinical-Pathologic Characteristics and Long-term Outcomes of Left Flexure Colonic Cancer: A Retrospective Analysis of an International Multicenter Cohort. Dis Colon Rectum 2020; 63:1593-1601. [PMID: 33149021 DOI: 10.1097/dcr.0000000000001785] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal cancer seldom presents at the splenic flexure. Small series on left flexure tumors reported a high occurrence of negative prognostic factors called into question as causes of poor prognosis. However, because of the small number of cases, no definite conclusions can be drawn. OBJECTIVE The aim of this study was to compare clinical-pathologic characteristics and short- and long-term outcomes of left flexure tumors with other colonic locations. DESIGN This was a retrospective analysis of consecutive patients who underwent surgery for tumors at the splenic flexure. Each tumor was paired in a 1 to 1 fashion with a right-sided and sigmoid tumor. SETTINGS The study was conducted in 10 international centers. PATIENTS A total of 641 patients with left flexure tumors were included in the study. MAIN OUTCOME MEASURES Overall survival and cancer-specific survival were measured. RESULTS Left flexure tumors presented more frequently with stenosis (30.5%; p < 0.001), with lesions infiltrating beyond the serosa (21.9%; p = 0.001) and with a high rate of mucinous histology (8.8%; p = 0.001). Looking at long-term prognosis, no differences were observed among the 3 groups, both considering overall and cancer-specific survival. However, left flexure tumors recurred more frequently as peritoneal carcinomatosis (20.6%; p < 0.001). LIMITATIONS This study was limited because of its retrospective nature. CONCLUSIONS Although left flexure tumors display several negative prognostic factors, they are not characterized by a worse prognosis compared with other colon cancer locations. See Video Abstract at http://links.lww.com/DCR/B395. CARACTERÍSTICAS CLÍNICO-PATOLÓGICAS Y RESULTADOS A LARGO PLAZO DEL CÁNCER DE COLON DE ÁNGULO IZQUIERDO: UN ANÁLISIS RETROSPECTIVO DE UNA COHORTE MULTICÉNTRICA INTERNACIONAL: El cáncer colorrectal rara vez se presenta en el ángulo esplénico. Pequeñas series sobre tumores de ángulo izquierdo informaron una alta incidencia de factores pronósticos negativos cuestionados como causas de mal pronóstico. Sin embargo, debido al pequeño número de casos, no se pueden sacar conclusiones definitivas.El objetivo de este estudio fue comparar las características clínico-patológicas, los resultados a corto y largo plazo de los tumores de ángulo izquierdo con otras ubicaciones de colon.Análisis retrospectivo de pacientes consecutivos que se sometieron a cirugía por tumores en el ángulo esplénico. Cada tumor se emparejó de forma individual con un tumor del lado derecho y sigmoide.El estudio se realizó en 10 centros internacionales.Se incluyeron en el estudio un total de 641 pacientes con tumores del ángulo izquierdo.Supervivencia general y específica del cáncerLos tumores de ángulo izquierda se presentaron con mayor frecuencia con estenosis (30.5%, p <0.001), con lesiones infiltradas más allá de la serosa (21.9%, p = 0.001), y con una alta tasa de histología mucinosa (8.8%, p = 0.001). En cuanto al pronóstico a largo plazo, no se observaron diferencias entre los tres grupos, considerando la supervivencia general y específica del cáncer. Sin embargo, los tumores de ángulo izquierdo recurrieron con mayor frecuencia como carcinomatosis peritoneal (20,6%; p <0,001).Este estudio fue limitado debido a su naturaleza retrospectiva.Aunque los tumores de ángulo izquierdo muestran varios factores pronósticos negativos, no se caracterizan por un peor pronóstico en comparación con otras ubicaciones de cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B395.
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Affiliation(s)
- Corrado Pedrazzani
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy
| | - Giulia Turri
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Koya Hida
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yudai Fukui
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Jacopo Crippa
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Giovanni Ferrari
- Department of General Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Origi
- Department of General Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gaya Spolverato
- First Surgical Clinic Section, Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Matteo Zuin
- First Surgical Clinic Section, Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Sung Uk Bae
- Division of Colorectal Surgery, Department of Surgery, School of Medicine, Keimyung University and Dongsan Medical Center, Daegu, Korea
| | - Seong Kyu Baek
- Division of Colorectal Surgery, Department of Surgery, School of Medicine, Keimyung University and Dongsan Medical Center, Daegu, Korea
| | - Andrea Costanzi
- General Surgery Unit, San Leopoldo Mandic Hospital Merate, ASST Lecco, Italy
| | - Dario Maggioni
- General Surgery Unit, San Leopoldo Mandic Hospital Merate, ASST Lecco, Italy
| | - Gyung Mo Son
- Department of Surgery, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Korea
| | - Andrea Scala
- Department of Colorectal and Minimal Access Surgery, Royal Surrey National Health Service Foundation Trust, Guildford, United Kingdom
| | - Timothy Rockall
- Department of Colorectal and Minimal Access Surgery, Royal Surrey National Health Service Foundation Trust, Guildford, United Kingdom
| | - Alfredo Guglielmi
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy
| | - Gyu Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - David W Larson
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Abd El Aziz MA, Grass F, Perry W, Behm KT, Shawki SF, Larson DW, Mathis KL. Colectomy for patients with super obesity: current practice and surgical morbidity in the United States. Surg Obes Relat Dis 2020; 16:1764-1769. [DOI: 10.1016/j.soard.2020.06.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/08/2020] [Accepted: 06/13/2020] [Indexed: 12/30/2022]
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Abd El Aziz MA, Perry WR, Grass F, Mathis KL, Larson DW, Mandrekar J, Behm KT. Predicting primary postoperative pulmonary complications in patients undergoing minimally invasive surgery for colorectal cancer. Updates Surg 2020; 72:977-983. [DOI: 10.1007/s13304-020-00892-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022]
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Achilli P, Radtke TS, Lovely JK, Behm KT, Mathis KL, Kelley SR, Merchea A, Colibaseanu DT, Larson DW. Preoperative predictive risk to cancer quality in robotic rectal cancer surgery. Eur J Surg Oncol 2020; 47:317-322. [PMID: 32928609 DOI: 10.1016/j.ejso.2020.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/30/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery. METHODS This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019. Pretreatment magnetic resonance imaging (MRI) reports were reviewed for all the patients. Risk factors for pathological CRM involvement were investigated using Firth's logistic regression and a predictive model based on preoperative radiological features was formulated. RESULTS A total of 305 patients were included, and 14 (4.6%) had CRM involvement. Multivariable logistic regression found both T3 >5 mm (OR 6.12, CI 1.35-36.44) and threatened or involved mesorectal fascia (OR 4.54, CI 1.33-17.55) on baseline MRI to be preoperative predictors of pathologic CRM positivity, while anterior location (OR 3.44, CI 0.72-33.13) was significant only on univariate analysis. The predictive model showed good discrimination (area under the receiver-operating characteristic curve >0.80) and predicted a 32% risk of positive CRM if all risk factors were present. CONCLUSION Patients with pre-operatively assessed threatened radiological margin, T3 tumors with greater than 5 mm extension and anterior location are at risk for a positive CRM. The predictive model can preoperatively estimate the CRM positivity risk for each patient, allowing surgeons to tailor management to improve oncological outcomes.
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Affiliation(s)
- Pietro Achilli
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
| | | | - Jenna K Lovely
- Reporting and Analytics, Mayo Clinic, Rochester, MN, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Achilli P, Crippa J, Grass F, Larson DW. Reply to: Comments on "Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database". Int J Cancer 2020; 148:1028-1029. [PMID: 33034382 DOI: 10.1002/ijc.33256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Pietro Achilli
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacopo Crippa
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Achilli P, Crippa J, Grass F, Mathis KL, D'Angelo ALD, Abd El Aziz MA, Day CN, Harmsen WS, Larson DW. Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database. Int J Cancer 2020; 148:161-169. [PMID: 32638371 DOI: 10.1002/ijc.33203] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 12/21/2022]
Abstract
Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy.
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Affiliation(s)
- Pietro Achilli
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacopo Crippa
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kellie L Mathis
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Courtney N Day
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota, USA
| | - William S Harmsen
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Larson DW, Abd El Aziz MA, Mandrekar JN. How Many Lives Will Delay of Colon Cancer Surgery Cost During the COVID-19 Pandemic? An Analysis Based on the US National Cancer Database. Mayo Clin Proc 2020; 95:1805-1807. [PMID: 32753157 PMCID: PMC7294269 DOI: 10.1016/j.mayocp.2020.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/03/2020] [Indexed: 01/18/2023]
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Shogan BD, Chen J, Duchalais E, Collins D, Chang M, Krull K, Krezalek MA, Larson DW, Walther-Antonio MR, Chia N, Nelson H. Alterations of the Rectal Microbiome Are Associated with the Development of Postoperative Ileus in Patients Undergoing Colorectal Surgery. J Gastrointest Surg 2020; 24:1663-1672. [PMID: 32323252 DOI: 10.1007/s11605-020-04593-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/02/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The most common complications after colorectal surgery, postoperative ileus, surgical site infections, and anastomotic leaks continue to occur despite advances in surgical technique and enhanced recovery pathways. Preclinical studies have documented that intestinal bacteria play a role in the development of these complication, yet human data is lacking. Here we hypothesized that patients that develop ileus, surgical site infection, and/or anastomotic leak following colorectal surgery harbor a specific preoperative gut microbiome. METHODS We performed a prospective cohort study on 101 patients undergoing colon or rectal resection at the Mayo Clinic. Rectal samples were collected preoperatively and on the ward on postoperative day two. The bacterial community from each sample was characterized by 16S rRNA and associated with the development of complications. RESULTS The rectal microbiome collected from patients in the operating room (p = .003) and on postoperative day two (p = .001) was significantly difference in patients whom later developed postoperative ileus compared with patients that had a normal return of bowel function. Patients whom developed ileus showed increased abundance of Bacteroides spp., Parabacteroides spp., and Ruminococcus spp., bacteria that are associated with promoting intestinal inflammation. There were no differences in the microbiome in patients that developed surgical site infections or anastomotic leaks. CONCLUSIONS In this pilot study, patients that develop postoperative ileus harbor a specific gut microbiome during the perioperative period. These findings demonstrate that the preoperative bacterial composition may predispose patients to the development of ileus and that perioperative manipulation of the gut bacteria may provide a novel method to promote normal return of bowel function.
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Affiliation(s)
- Benjamin D Shogan
- Division of Colon and Rectal Surgery, University of Chicago, Room J557F, MC 5095, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
| | - Jun Chen
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Emilie Duchalais
- Department of Digestive and Endocrine Surgery, CHU de Nantes, Nantes, France
| | | | - Melissa Chang
- Department of Surgery, St. Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Kimberly Krull
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Monika A Krezalek
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Nicholas Chia
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Heidi Nelson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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