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Kobelt M, Waldhauser GT, Rupietta A, Heinen R, Rau EMB, Kessler H, Axmacher N. The memory trace of an intrusive trauma-analog episode. Curr Biol 2024; 34:1657-1669.e5. [PMID: 38537637 DOI: 10.1016/j.cub.2024.03.005] [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] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/05/2023] [Accepted: 03/06/2024] [Indexed: 04/25/2024]
Abstract
Intrusive memories are a core symptom of posttraumatic stress disorder. Compared with memories of everyday events, they are characterized by several seemingly contradictory features: intrusive memories contain distinct sensory and emotional details of the traumatic event and can be triggered by various perceptually similar cues, but they are poorly integrated into conceptual memory. Here, we conduct exploratory whole-brain analyses to investigate the neural representations of trauma-analog experiences and how they are reactivated during memory intrusions. We show that trauma-analog movies induce excessive processing and generalized representations in sensory areas but decreased blood-oxygen-level-dependent (BOLD) responses and highly distinct representations in conceptual/semantic areas. Intrusive memories activate generalized representations in sensory areas and reactivate memory traces specific to trauma-analog events in the anterior cingulate cortex. These findings provide the first evidence of how traumatic events could distort memory representations in the human brain, which may form the basis for future confirmatory research on the neural representations of traumatic experiences.
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Affiliation(s)
- M Kobelt
- Department of Neuropsychology, Ruhr-Universität Bochum, Bochum 44801, North Rhine-Westphalia, Germany.
| | - G T Waldhauser
- Department of Neuropsychology, Ruhr-Universität Bochum, Bochum 44801, North Rhine-Westphalia, Germany.
| | - A Rupietta
- Department of Clinical Psychology and Psychotherapy, Ruhr-Universität Bochum, Bochum 44787, North Rhine-Westphalia, Germany
| | - R Heinen
- Department of Neuropsychology, Ruhr-Universität Bochum, Bochum 44801, North Rhine-Westphalia, Germany
| | - E M B Rau
- Department of Neuropsychology, Ruhr-Universität Bochum, Bochum 44801, North Rhine-Westphalia, Germany
| | - H Kessler
- Department of Psychosomatic Medicine and Psychotherapy, Campus Fulda, Universität Marburg, Marburg 35032, Hessen, Germany; Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr-Universität Bochum, Bochum 44791, North Rhine-Westphalia, Germany
| | - N Axmacher
- Department of Neuropsychology, Ruhr-Universität Bochum, Bochum 44801, North Rhine-Westphalia, Germany.
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Kessler H, Luna Russo M, King C, Sobrado LF. Laparoscopic low anterior resection for deeply infiltrating endometriosis - a video vignette. Colorectal Dis 2024. [PMID: 38572790 DOI: 10.1111/codi.16944] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 10/14/2023] [Accepted: 10/24/2023] [Indexed: 04/05/2024]
Affiliation(s)
- H Kessler
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - M Luna Russo
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - C King
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - L F Sobrado
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
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Holubar SD, Lipman J, Steele SR, Uchino T, Lincango EP, Liska D, Ban K, Rosen D, Sommovilla J, Gorgun E, Kessler H, Valente M, Hull T. Safety & feasibility of targeted mesenteric approaches with Kono-S anastomosis and extended mesenteric excision in ileocolic resection and anastomosis in Crohn's disease. Am J Surg 2024; 230:16-20. [PMID: 37914660 DOI: 10.1016/j.amjsurg.2023.10.050] [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: 08/11/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The mesentery has recently been implicated in the pathophysiology of Crohn's disease (CD), and several techniques have been developed to target the mesentery to reduce its influence on recurrence. We aimed to describe short-term safety and feasibility after these approaches. METHODS This is a comparative, retrospective, single-center cohort study of consecutive CD patients undergoing primary or redo ileocolic resection from 2015 to 2022 with Kono-S anastomosis (KSA), extended mesenteric excision (EME) only, or both: mesenteric excision and exclusion (MEE). RESULTS 186 patients underwent KSA (n = 74), EME (n = 66), or MEE (n = 46). The groups had comparable baseline characteristics. The MEE group operative time was longer (median: 187 vs. KSA 170, EME 152 min, p < 0.01). Postoperatively, the groups had similar lengths of stay (median 4 days), readmissions (9.1 %), major postoperative complications (6.5 %), and anastomotic leaks (1.1 %). CONCLUSION Targeting the mesentery with novel surgical approaches for ileocolic Crohn's disease was safe and feasible for short-term follow-up.
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Affiliation(s)
- Stefan D Holubar
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Jeremy Lipman
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tairin Uchino
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eddy P Lincango
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kristen Ban
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Rosen
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joshua Sommovilla
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hermann Kessler
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael Valente
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tracy Hull
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
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Maspero M, Liska D, Kessler H, Lipman J, Steele SR, Hull T, Qazi T, Rieder F, Cohen B, Holubar SD. Redo IPAA for long rectal cuff syndrome after ileoanal pouch for inflammatory bowel disease. Tech Coloproctol 2024; 28:38. [PMID: 38451358 DOI: 10.1007/s10151-023-02909-9] [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: 10/10/2023] [Accepted: 12/24/2023] [Indexed: 03/08/2024]
Abstract
ABTRACT BACKGROUND: When constructing an ileal pouch-anal anastomosis (IPAA), the rectal cuff should ideally be 1-2 cm long to avoid subsequent complications. METHODS We identified patients from our IBD center who underwent redo IPAA for a long rectal cuff. Long rectal cuff syndrome (LRCS) was defined as a symptomatic rectal cuff ≥ 4 cm. RESULTS Forty patients met the inclusion criteria: 42.5% female, median age at redo surgery 42.5 years. The presentation was ulcerative proctitis in 77.5% of the cases and outlet obstruction in 22.5%. The index pouch was laparoscopically performed in 18 patients (45%). The median rectal cuff length was 6 cm. The pouch was repaired in 16 (40%) cases, whereas 24 (60%) required the creation of a neo-pouch. At the final pathology, the rectal cuff showed chronic active colitis in 38 (90%) cases. After a median follow-up of 34.5 (IQR 12-109) months, pouch failure occurred in 9 (22.5%) cases. The pouch survival rate was 78% at 3 years. Data on the quality of life were available for 11 (27.5%) patients at a median of 75 months after redo surgery. The median QoL score (0-1) was 0.7 (0.4-0.9). CONCLUSION LRCS, a potentially avoidable complication, presents uniformly with symptoms of ulcerative proctitis or stricture. Redo IPAA was restorative for the majority.
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Affiliation(s)
- Marianna Maspero
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - David Liska
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Hermann Kessler
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Jeremy Lipman
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Taha Qazi
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Cohen
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA.
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Schabl L, Lincango E, Kessler H. Laparoscopic right hemicolectomy with complete mesocolic excision-inferior approach (with video). J Visc Surg 2024:S1878-7886(24)00003-1. [PMID: 38378304 DOI: 10.1016/j.jviscsurg.2024.01.003] [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] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Lukas Schabl
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500, Euclid Ave./A 30, Cleveland, OH 44195, USA.
| | - Eddy Lincango
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500, Euclid Ave./A 30, Cleveland, OH 44195, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500, Euclid Ave./A 30, Cleveland, OH 44195, USA
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Schabl L, Holubar SD, Erozkan K, Alipouriani A, Sancheti H, Steele SR, Kessler H. Epidemiology and age-related trends in surgical outcomes for sigmoid volvulus: a 17-year analysis. Langenbecks Arch Surg 2024; 409:37. [PMID: 38217626 DOI: 10.1007/s00423-024-03228-9] [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: 11/13/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Sigmoid volvulus, a gastrointestinal disorder characterized by twisted bowel, often requires medical intervention, either through endoscopic or surgical means, to avoid potentially severe outcomes. This study examined the challenges elderly patients face in undergoing surgical treatment, encompassing both mortality and morbidity. Furthermore, it aimed to determine how medical practices and outcomes have changed over a period of 17 years. METHODS We utilized data from the National Surgical Quality Improvement Project, which covers the period from 2005 to 2021, to identify patients who underwent left hemicolectomy for colonic volvulus. The patients were categorized into three age groups: < 60 years, 60-75 years, and > 75 years. We performed a meticulous logistic regression analysis, carefully adjusted for risk factors, to compare mortality, morbidity, and types of surgical treatment administered among the different age groups. RESULTS Our study included 6775 patients. The breakdown of the patient population was as follows: 2067 patients were < 60 years of age, 2239 were between 60 and 75 years of age, and 2469 were > 75 years of age. The elderly cohort, those aged above 75 years, were predominantly male, had lower BMIs, underwent fewer laparoscopic surgeries, required more diverting stomas and end-ostomies, and had longer hospital stays. Notably, the elderly population faced a mortality risk that was 5.67 times (95% CI 3.64, 9.20) greater than that of their youngest counterparts, with this risk increasing by 10% (95% CI 1.06, 1.14) for each additional year of age. Furthermore, the odds of mortality associated with emergency surgery were 1.63 times (95% CI 1.21, 2.22) higher than those associated with elective surgery. The postoperative morbidity odds were also elevated for emergency surgeries, 1.30 times (95% CI 1.08, 1.58) greater than that for elective cases. Over the 17-year period, we observed a decline in mortality rates, an increase in the utilization of laparoscopic procedures, and overall stability of morbidity rates. CONCLUSION Our findings highlight the increased vulnerability of patients over 75 years of age, who are not only at an elevated risk of mortality compared to their younger counterparts, but also a continuously increasing risk with age. By focusing on elective surgeries for younger patients and minimizing emergency surgeries for the elderly, it may be possible to reduce the mortality risk associated with surgical interventions in this population.
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Affiliation(s)
- Lukas Schabl
- Department for Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
- Department for General, Visceral, and Thoracic Surgery, University Hospital Salzburg, Salzburg, Austria.
| | - Stefan D Holubar
- Department for Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kamil Erozkan
- Department for Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Alipouriani
- Department for Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Himani Sancheti
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department for Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hermann Kessler
- Department for Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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Maspero M, Otero A, Lavryk O, Holubar SD, Lipman J, Gorgun E, Liska D, Kessler H, Valente M, Steele SR, Hull T. Incidental Dysplasia During Total Proctocolectomy With Ileoanal Pouch: Is It Associated With Worse Outcomes? Inflamm Bowel Dis 2023:izad263. [PMID: 37963567 DOI: 10.1093/ibd/izad263] [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: 04/14/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) are at increased risk of colorectal cancer. In cases of invisible or nonendoscopically resectable dysplasia found at colonoscopy, total proctocolectomy with ileal pouch anal anastomosis can be offered with good long-term outcomes; however, little is known regarding cancer-related outcomes when dysplasia is found incidentally after surgery on final pathology. METHODS Using our prospectively collected pouch registry, we identified patients who had preoperative colonic dysplasia or dysplasia found only after colectomy. Patients with cancer preoperatively or after colectomy were excluded. Included patients were divided into 3 groups: PRE (+preoperative biopsy, negative final pathology), BOTH (+preoperative biopsy and final pathology), and POST (negative preoperative biopsy, +final pathology). Long-term outcomes in the 3 groups were assessed. RESULTS In total, 517 patients were included: PRE = 125, BOTH = 254, POST = 137. After a median follow-up of 12 years (IQR 3-21), there were no differences in overall, disease-free, or pouch survival between groups. Cancer/dysplasia developed in 11 patients: 3 (2%) in the PRE, 5 (2%) in the BOTH, and 3 (2%) in the POST group. Only 1 cancer-related death occurred in the entire cohort (PRE group). Disease-free survival at 10 years was 98% for all groups (P = .97). Pouch survival at 10 years was 96% for PRE, 99% for BOTH, and 97% for POST (P = .24). CONCLUSIONS The incidental finding of dysplasia on final pathology after proctocolectomy was not associated with worsened outcomes compared with preoperatively diagnosed dysplasia.
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Affiliation(s)
- Marianna Maspero
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ana Otero
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Olga Lavryk
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jeremy Lipman
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Emre Gorgun
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - David Liska
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hermann Kessler
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael Valente
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Maspero M, Lavryk O, Lipman J, Valente M, Kessler H, Holubar S, Steele SR, Hull T. Redo ileal pouch-anal anastomosis for early versus late sepsis-related pouch failure. Surgery 2023; 174:801-807. [PMID: 37543468 DOI: 10.1016/j.surg.2023.06.016] [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] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/24/2023] [Accepted: 06/18/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Pouch failure after restorative proctocolectomy with ileal pouch-anal anastomosis occurs in 5% to 15% of cases, mostly due to septic complications. We aimed to determine if the timing of pouch failure impacted long-term outcomes for redo ileal pouch-anal anastomosis after sepsis-related complications. METHOD We retrospectively analyzed our prospectively collected institutional pouch database. Patients who underwent redo ileal pouch-anal anastomosis for septic complications between 1988 and 2020 were divided into an early (pouch failure within 6 months of stoma closure after index operation, or stoma never closed) and a late failure group (pouch failure after 6 months of stoma closure). The primary endpoint was pouch survival. RESULTS In total, 335 patients were included: 241 (72%) in the early and 94 (28%) in the late failure group. The most common indication for failure was an anastomotic leak in the early failure group (163, 68%) and fistula in the late failure group (59, 63%), P < .001. Pouch survival at 3, 5, and 10 years was 77%, 75%, and 72% for the early and 79%, 75%, and 68% for the late failure group (P = .94). The most common reason for redo pouch failure was fistula in both groups. Quality of life was similar in both groups. In multivariate analysis, the only factor associated with pouch failure was the final diagnosis of Crohn's disease. CONCLUSION Outcomes after redo ileal pouch-anal anastomosis were comparable between patients with early and late sepsis-related index pouch failure, with acceptable rates of long-term pouch survival and good quality of life.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH. https://twitter.com/MariannaMaspero
| | - Olga Lavryk
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH. https://twitter.com/OlgaLavryk
| | - Jeremy Lipman
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH
| | - Michael Valente
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH
| | - Hermann Kessler
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH. https://twitter.com/HolubarStefan
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH. https://twitter.com/ScottRSteeleMD
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH.
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Maspero M, Lavryk O, Lipman J, DeRoss A, Kessler H, Holubar S, Steele SR, Hull T. Long-term Outcomes of Straight Ileoanal Anastomoses Converted to Ileal Pouch Anal Anastomoses. J Pediatr Surg 2023; 58:1898-1902. [PMID: 37005207 DOI: 10.1016/j.jpedsurg.2023.03.001] [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: 12/29/2022] [Revised: 02/22/2023] [Accepted: 03/04/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND While ileal pouch anal anastomosis (IPAA) is the recommended way to restore intestinal continuity after total proctocolectomy, straight ileoanal anastomoses (SIAA) are still selectively performed, especially in the pediatric population. In case of SIAA failure, conversion to IPAA is possible, but reports on its outcomes are scarce. METHODS We retrospectively analyzed our prospectively collected database on pelvic pouches, and identified patients with a SIAA that was converted to IPAA. Our aim was long-term functional outcomes. RESULTS Twenty-three patients were included (14 females, median age at SIAA 15 years, median age at conversion to IPAA 19 years). The indication for SIAA was ulcerative colitis in 17 (74%) cases, indeterminate colitis in 2 (9%) cases, and familial adenomatous polyposis in 4 (17%) cases. The indication for IPAA conversion was incontinence/poor quality of life in 12 (52%) cases, sepsis in 8 (35%) cases, anastomotic stricture in 2 (9%) cases, and prolapse in one (4%) case. The majority were diverted at IPAA conversion (22, 96%). Three (13%) patients never had stoma closure, due to patient wishes, failed healing of vaginal fistula, and pelvic sepsis, respectively. After a median follow up of 109 months (28-170), pouch failure occurred in 5 additional patients. Overall pouch survival was 71% at 5 years. Median quality of life was 8/10, of health 8/10, and of energy 7/10. Median satisfaction with surgery was 9.5/10. CONCLUSION Conversion of SIAA to IPAA leads to acceptable long-term outcomes and good quality of life, and can safely be offered to patients with problems related to SIAA. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Marianna Maspero
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Olga Lavryk
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jeremy Lipman
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Anthony DeRoss
- Department of Pediatric Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
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10
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Duraes LC, Kalady MF, Liska D, Gorgun E, Kessler H, Otero-Pineiro A, Steele SR, Valente MA. Word of caution: Rectal cancer without response to neoadjuvant treatment - Do not wait for surgery. Am J Surg 2023; 226:548-552. [PMID: 37032235 DOI: 10.1016/j.amjsurg.2023.03.021] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 02/05/2023] [Accepted: 03/22/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND We hypothesized that prolonging the interval to surgery in non-responders to neoadjuvant chemoradiation therapy (nCRT) could lead to worse oncologic outcomes. METHODS Rectal adenocarcinoma patients with poor tumor response to nCRT (AJCC tumor regression grade 3) were selected. Oncologic outcomes were evaluated according to the time interval between completion of nCRT and surgery. RESULTS Among 56 non-responders, 28 patients surgically treated ≥8 weeks after completion of nCRT had worse disease-free survival (31% vs. 49%, p = 0.05) and worse overall survival (34% vs. 53%, p = 0.02) compared to patients <8 weeks. Using the three different intervals (≥12 weeks, 6-12 weeks, and< 6 weeks), waiting longer was consistently associated with worse overall (23% vs. 48% vs. 63%, p = 0.02) and worse cancer-specific survival (35% vs. 61% vs. 71%, p = 0.04), respectively. CONCLUSION For rectal cancer patients who are non-responders to nCRT, delay of surgery may lead to worse oncologic outcomes.
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Affiliation(s)
- Leonardo C Duraes
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew F Kalady
- Division of Colon and Rectal Surgery, The Ohio State University, Columbus, OH, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ana Otero-Pineiro
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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11
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Christiansen A, Connelly TM, Lincango EP, Falcone T, King C, Kho R, Russo ML, Jia X, Valente M, Kessler H. Endometriosis with colonic and rectal involvement: surgical approach and outcomes in 142 patients. Langenbecks Arch Surg 2023; 408:385. [PMID: 37773225 DOI: 10.1007/s00423-023-03095-w] [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: 03/23/2023] [Accepted: 09/05/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE Endometriosis involving the colon and/or rectum (CRE) is operatively managed using various methods. We aimed to determine if a more limited excision is associated with 30-day complications, symptom improvement, and/or recurrence. METHODS This is a retrospective review of consecutive cases of patients who underwent surgical management of CRE between 2010 and 2018. Primary outcomes were the associations between risk factors and symptom improvement, 30-day complications, and time to recurrence. Multivariable logistic regression assessed the independent risk factors. RESULTS Of 2681 endometriosis cases, 142 [5.3% of total, mean age 35.4 (31.0; 39.0) years, 73.9% stage IV] underwent CRE excision (superficial partial = 66.9%, segmental = 27.5%, full thickness = 1.41%). Minor complications (14.8%) were associated with blood loss [150 (112; 288) vs. 100 (50.0; 200) mls, p = 0.046], Sigmoid involvement [45.5% vs. 12.2%, HR 5.89 (1.4; 22.5), p = 0.01], stoma formation [52.6% vs. 8.9%, HR 10.9 (3.65; 34.1), p < 0.001], and segmental resection [38.5% vs. 5.8%, HR 9.75 (3.54; 30.4), p < 0.001]. Superficial, partial-thickness resections were associated with decreased risk [(4.2% vs. 36.2%), HR 0.08 (0.02; 0.24), p < 0.001]. Factors associated with major complications (8.5%) were blood loss [250 (100; 400) vs. 100 (50.0; 200) mls, p = 0.03], open surgery [31.6% vs. 4.9%, HR 8.74 (2.36; 32.9), p = 0.001], stoma formation [42% vs. 3.3%, HR 20.3 (5.41; 90.0), p < 0.001], and segmental colectomy [28.2% vs. 0.9%, HR 34.6 (6.25; 876), p < 0.001]. Partial-thickness resection was associated with decreased risk ([.05% vs. 23.4%, HR 8.74 (2.36; 32.9), p < 0.001]. 19.1% experienced recurrence. Open surgery [5.2% vs. 21.3%, HR 0.14 (0.02; 1.05), p = 0.027] and superficial partial thickness excision [23.4% vs. 10.6%, HR 2.86 (1.08; 7.59), p = 0.027] were associated. Segmental resection was associated with decreased recurrence risk [7.6% vs. 23.5%, HR 0.27 (0.08; 0.91), p = 0.024]. CONCLUSION Limiting resection to partial-thickness or full-thickness disc excision compared to bowel resection may improve complications but increase recurrence risk.
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Affiliation(s)
| | - Tara M Connelly
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Eddy P Lincango
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Tommaso Falcone
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Cara King
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Rosanne Kho
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Miguel Luna Russo
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Xue Jia
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Michael Valente
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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12
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Schabl L, Connelly T, Steele S, Kessler H. Giant rectal vascular malformation: a rare differential diagnosis in rectal bleeding. BMJ Case Rep 2023; 16:e256038. [PMID: 37770238 PMCID: PMC10546121 DOI: 10.1136/bcr-2023-256038] [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] [Indexed: 09/30/2023] Open
Abstract
Investigations in a woman with prolonged symptoms of laxative-resistant constipation and recurrent rectal bleeding revealed a giant rectal vascular malformation. Colonoscopy and MRI were performed to rule out malignancy and determine differential diagnoses. Repeated tests were necessary due to inconclusive results. After a definite diagnosis, image-guided, transcutaneously administered sclerotherapy was used. The intervention and postoperative course were uneventful. A minimally invasive procedure relieved symptoms and improved quality of life.
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Affiliation(s)
- Lukas Schabl
- Department of Colorectal Surgery, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, USA
- Department of General, Visceral and Thoracic Surgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tara Connelly
- Department of Pediatric Surgery, King's College Hospital, London, UK
| | - Scott Steele
- Department of Colorectal Surgery, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, USA
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13
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Connelly TM, Cheong JY, Lincango EP, Foley N, Clancy C, Valente M, Kessler H. Low incidence of occult colorectal carcinoma in a cohort of 150 consecutive patients with diverticular strictures. Surgery 2023; 174:487-491. [PMID: 37296056 DOI: 10.1016/j.surg.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/23/2023] [Accepted: 04/09/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The symptoms of stricturing diverticulitis can overlap with those of colorectal cancer. Additionally, the stricture itself may mask a "hidden" colorectal cancer. We aimed to describe the demographics, operative details and outcomes, including occult colorectal cancer, in a cohort of consecutive resections for presumed diverticular strictures. METHODS In this single-center, retrospective cohort study, all patients undergoing resection for a presumed diverticular stricture between January 2010 and December 2015 were included. Preoperative imaging and colonoscopies were individually reviewed. Only patients with radiographically, endoscopically and/or intraoperatively benign-appearing strictures were included. RESULTS One hundred fifty patients (72.7% female, mean age = 70.4 ± 11.8 years, 62.7% elective) were included. Only 34 (22.7%) had a complete preoperative colonoscopy. In 95 (63.6% of cohort) patients, the stricture was non-traversable colonoscopically. Overall, 47 (31.3%) patients did not have complete preoperative imaging or a colonoscopy. In total, 53.3% were open procedures and 62% had non-diverted primary anastomosis. Eleven (14.7%) underwent resection of adjacent organs (5 appendixes/5 right colons/7 fallopian tubes ± ovaries/3 small bowel resections/2 partial cystectomies/1 spleen). The median length of stay was 7 (5, 12.5) days. Only 2 cancers (1.3% of patients) involving the stricture (1 invasive moderately differentiated sigmoid adenocarcinoma/1 lymphoma) were found. Three additional cancers were found in organs involved in the inflammatory process (20% of concomitantly resected organs, 1 ovarian carcinoma/1 leukemia in a lymph node/1 appendiceal tumor). CONCLUSION Despite approximately one-third of the cohort not having undergone successful preoperative colonoscopy or imaging, the rate of neoplasia involving diverticular strictures was only 1.3%. A relatively high cancer rate was found in concomitantly resected organs involved in the stricturing process.
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Affiliation(s)
- Tara M Connelly
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/TaraMConnelly
| | - Ju Yong Cheong
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/JUYONGCHEONG1
| | - Eddy P Lincango
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/DoctorEddyMD
| | - Niamh Foley
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/nnifhoghlu
| | - Cillian Clancy
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH
| | - Michael Valente
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/DrMikeValente
| | - Hermann Kessler
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH.
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14
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Sapci I, GamalEldin M, Rencuzogullari A, Yilmaz S, Kessler H, Hull T, Delaney CP, Steele SR, Gorgun E. Prospective randomized comparison of three-dimensional (3D) versus conventional laparoscopy in total colectomy for ulcerative colitis. ANZ J Surg 2023; 93:2155-2160. [PMID: 36898957 DOI: 10.1111/ans.18368] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/22/2023] [Accepted: 02/25/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND 3D laparoscopy has been proposed with the aim of improving the depth perception and overall operative performance. To aim of this study is to compare 3D laparoscopy with conventional 2D laparoscopy in terms of operative time and visual parameters. METHODS This is a prospective, randomized, single-center trial designed to determine 10% reduction in the mean operative time. Ulcerative colitis patients >18 years of age who underwent laparoscopic total abdominal colectomy with end ileostomy between 2015 and 2020 were included. Patients were randomized into 3D and 2D laparoscopy groups. Duration of operation and surgeons' evaluation of the visualization system were the primary outcomes. RESULTS Fifty-three subjects (26 in 2D, 27 in 3D group) were included in the analysis, with 56% being male. Mean age and body mass index were 40 (16.3) years and 23.5 (4.7) kg/m2 , respectively. Twenty-five subjects underwent single port laparoscopic surgery, of whom 13 were in 3D and 12 in 2D group. Mean operative time was 75.3 (30.8) versus 82.7 (38.6) minutes (P = 0.4) for 3D and 2D groups, respectively. Operative times spent for individual steps were comparable. Post-operative minor complications (8 in 3D versus 8 in 2D, P = 1) and median number of times for scope maintenance were also similar between the groups. 69% of the visual evaluation survey results favoured 3D over 2D (P = 0.014). CONCLUSION Three-dimensional laparoscopy for total colectomy in ulcerative colitis patients is safe and feasible option providing better visualization with no difference in operative time.
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Affiliation(s)
- Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Maysoon GamalEldin
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Ahmet Rencuzogullari
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Sumeyye Yilmaz
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
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Lincango EP, Cheong JY, Prien C, Connelly TM, Hernandez Dominguez O, Tursun N, Liska D, Lipman J, Lightner A, Kessler H, Valente MA, Hull T, Steele SR, Holubar SD. Idiopathic myointimal hyperplasia of the mesenteric veins: A systematic review of surgical management. Surgery 2023; 174:473-479. [PMID: 37301609 DOI: 10.1016/j.surg.2023.04.014] [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] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/31/2023] [Accepted: 04/09/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Idiopathic myointimal hyperplasia of the mesenteric veins is an extremely rare non-thrombotic mesenteric veno-occlusive disease. The management of idiopathic myointimal hyperplasia of the mesenteric veins is not well-established, and although surgery is the mainstay of treatment, the optimal operation remains unclear. Therefore, we aimed to perform a systematic review to assess the various surgical procedures and associated outcomes for patients with idiopathic myointimal hyperplasia of the mesenteric veins. METHODS A systematic search for articles published from 1946 to April 2022 in MEDLINE, EMBASE, Cinahl, Scopus, Web of Science, and Cochrane Library databases is reported. In addition, we report 4 cases of idiopathic myointimal hyperplasia of the mesenteric veins managed at our institution until March 2023. RESULTS A total of 53 studies and 88 patients with idiopathic myointimal hyperplasia of the mesenteric veins were included. Most (82%) were male patients, with a mean age of 56.6 years old. The majority (99%) of patients required surgery. Most reports described the involvement of the rectum and sigmoid colon (81%). The most common surgical procedures were Hartmann's procedure (24%) and segmental colectomy (19%); completion proctectomy with ileal pouch-anal anastomosis was performed in 3 (3.4%) cases. In 6 (6.8%) cases, idiopathic myointimal hyperplasia of the mesenteric veins was suspected preoperatively and managed with elective surgery. Four (4.5%) complications were reported. Nearly all (99%) patients achieved remission with surgical intervention. CONCLUSION Idiopathic myointimal hyperplasia of the mesenteric veins is a rare pathologic entity infrequently suspected preoperatively and typically diagnosed after surgical resection. Surgical resection with Hartmann's procedure or segmental colectomy was most commonly performed, with completion proctectomy and ileal pouch-anal anastomosis reserved for cases of extensive rectal involvement. Surgical resection was safe and effective, with a low risk of complications and recurrence. Surgical decision-making should be based on the extent of the disease at the time of presentation.
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Affiliation(s)
- Eddy P Lincango
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Ju Yong Cheong
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Christopher Prien
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Tara M Connelly
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | | | - Naz Tursun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Jeremy Lipman
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Amy Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH.
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16
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Connelly TM, Cheong JY, Lincango EP, Foley N, Duraes LC, Kessler H. Surgery for young onset diverticulitis: is it curative? Int J Colorectal Dis 2023; 38:195. [PMID: 37452913 DOI: 10.1007/s00384-023-04479-6] [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] [Accepted: 11/28/2022] [Indexed: 07/18/2023]
Abstract
PURPOSE Previously considered a disease of old age, diverticular disease is increasingly prevalent in younger populations. Guidelines on surgical resection have shifted from recommending resection for all young onset patients to an individualized approach. Therefore, we aim to determine demographics and outcomes including radiographic and surgical recurrence rates in patients < 40 years old undergoing resection for diverticular disease. METHODS A retrospective, single center study was performed. All patients ≤ 39 years undergoing operative intervention for left-sided diverticular disease between Jan 2010 and July 2017 were included. Recurrence was determined by individual review of imaging and operative reports. RESULTS Overall, 147 (n = 107/72.8% male, mean age = 34.93 ± 4.12 years) patients were included. The majority were ASA 1 or 2 (n = 41/27.9% and n = 82/55.8%). The most common surgical indication was uncomplicated diverticulitis (n = 77, 52.4%) followed by perforation (n = 26/17.7%). The majority (n = 108/73.5%) of cases were elective. Seventy-nine (57.3%) of all cases were performed laparoscopically. Primary anastomosis without diversion was the most common surgical outcome (n = 108/73.5%). Median length of stay was 5 (4, 7) days. There was no mortality. There were three (2.0%) intraoperative and 38 (25.9%) postoperative complications. The most common complication was anastomotic leak (n = 6/4.1%). The majority (n = 5) of leaks occurred after elective surgery. Two neoplastic lesions (1.3% of cohort) were found (1 adenoma with low-grade dysplasia/1 polyp cancer). Over a mean follow-up of 96 (74, 123) months, only 2 (1.3%) patients experienced a surgical or radiological recurrence. CONCLUSION Both neoplasia and recurrence after resection for diverticular disease in young onset patients are rare. Leaks after primary anastomosis even in the elective setting warrant careful consideration of a defunctioning ileostomy.
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Affiliation(s)
- Tara M Connelly
- Dept. of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Ju Yong Cheong
- Dept. of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Eddy P Lincango
- Dept. of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Niamh Foley
- Dept. of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Leonardo C Duraes
- Dept. of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Hermann Kessler
- Dept. of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA.
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Xu Z, Valente MA, Sklow B, Liska D, Gorgun E, Kessler H, Rosen DR, Steele SR. Impact of Total Neoadjuvant Therapy on Postoperative Outcomes After Proctectomy for Rectal Cancer. Dis Colon Rectum 2023; 66:1022-1028. [PMID: 36538720 DOI: 10.1097/dcr.0000000000002555] [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 Total neoadjuvant therapy is an alternative to neoadjuvant chemoradiation alone for rectal cancer and has the benefits of more completion of planned therapy, increased downstaging, earlier treatment of micrometastases, and assessment of chemosensitivity; however, it may increase surgical complications, especially with increased radiation-to-surgery interval. OBJECTIVE The study aimed to determine the impact of total neoadjuvant therapy on postoperative complications compared with neoadjuvant chemoradiation alone. DESIGN Retrospective cohort study. SETTINGS Single tertiary referral center. PATIENTS The patient included was a stage II/III rectal cancer patient who underwent total neoadjuvant therapy or long-course neoadjuvant chemoradiation followed by surgical resection from 2018-2020. MAIN OUTCOME MEASURES The main outcome measures included severe postoperative complications (Clavien-Dindo grade ≥3). RESULTS Of 181 patients, 86 (47.5%) underwent total neoadjuvant therapy and 95 (52.5%) underwent neoadjuvant chemoradiation. There was no difference in severe postoperative complications or any complications. There was also no difference in the rate of complete total mesorectal excision or negative circumferential margin. Total neoadjuvant therapy had a mean operative time of 355.5 minutes and estimated blood loss of 263.6 mL compared with 326.7 minutes and 297.5 mL in the neoadjuvant chemoradiation group. Total neoadjuvant therapy patients had a lower mean lymph node yield than neoadjuvant chemoradiation patients. On multivariable analysis, total neoadjuvant therapy was associated with increased operative time (OR, 1.19; p < 0.001) and estimated blood loss (OR, 1.22; p < 0.001) and decreased lymph node yield (OR, 0.67; p < 0.001). There was no difference in severe complications or any complications. LIMITATIONS Selection bias uncontrolled by modeling. CONCLUSIONS We found no difference in risk of postoperative complications between patients who received total neoadjuvant therapy vs neoadjuvant chemoradiation. Total neoadjuvant therapy patients had longer operations and greater estimated blood loss. This may be a reflection of increased operative difficulty because of increased radiation-to-surgery interval and/or the effects of chemotherapy; however, the absolute differences were small and, therefore, should be interpreted cautiously. See Video Abstract at http://links.lww.com/DCR/C44 . IMPACTO DE LA TERAPIA NEOADYUVANTE TOTAL EN LOS RESULTADOS POSOPERATORIOS DESPUS DE UNA PROCTECTOMA POR CNCER DE RECTO ANTECEDENTES:La terapia neoadyuvante total es una alternativa a la quimiorradiación neoadyuvante sola para el cáncer de recto y tiene los beneficios de una mayor finalización de la terapia planificada, mayor reducción del estadiage, tratamiento más temprano de las micrometástasis y evaluación de la quimiosensibilidad; sin embargo, puede aumentar las complicaciones quirúrgicas, especialmente con un mayor intervalo entre la radiación y la cirugía.OBJETIVO:Determinar el impacto de la terapia neoadyuvante total sobre las complicaciones posoperatorias en comparación con la quimiorradiación neoadyuvante sola.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro único de referencia terciario.PACIENTES:Paciente con cáncer de recto en estadio II/III que se sometieron a terapia neoadyuvante total o quimiorradiación neoadyuvante de larga duración seguida de resección quirúrgica entre 2018 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias graves (grado de Clavien-Dindo ≥3).RESULTADOS:De 181 pacientes, 86 (47,5%) se sometieron a terapia neoadyuvante total y 95 (52,5%) se sometieron a quimiorradioterapia neoadyuvante. No hubo diferencia en las complicaciones postoperatorias graves o cualquier otra complicación. Tampoco hubo diferencia en la tasa de escisión mesorrectal total completa o margen circunferencial negativo. La terapia neoadyuvante total tuvo un tiempo operatorio promedio de 355,5 minutos y una pérdida de sangre estimada de 263,6 ml en comparación con 326,7 minutos y 297,5 ml en el grupo de quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron una media de ganglios linfáticos más bajo en comparación con los pacientes con quimiorradioterapia neoadyuvante. En el análisis multivariable, la terapia neoadyuvante total se asoció con un mayor tiempo operatorio (OR = 1,19, p < 0,001) y pérdida de sangre estimada (OR = 1,22, p < 0,001) y menor cantidad los ganglios linfáticos (OR = 0,67, p < 0,001). No hubo diferencia en las complicaciones graves o cualquier complicación.LIMITACIONES:Sesgo de selección no controlado por modelado.CONCLUSIONES:No encontramos diferencias en el riesgo de complicaciones postoperatorias entre los pacientes que recibieron terapia neoadyuvante total versus quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron operaciones más prolongadas y una mayor pérdida de sangre estimada. Esto puede ser un reflejo de una mayor dificultad quirúrgica como resultado de un mayor intervalo entre la radiación y la cirugía y/o los efectos de la quimioterapia; sin embargo, las diferencias absolutas fueron pequeñas y, por lo tanto, deben interpretarse con cautela. Consulte Video Resumen en http://links.lww.com/DCR/C44 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Affiliation(s)
- Zhaomin Xu
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Benlice C, Parvaiz A, Baca B, Hohenberger W, Miskovic D, Stocchi L, Steele S, Kim SH, Holm T, Spinelli A, Gogenur I, Panis Y, Hasegawa H, Karachun A, Uriburu JCP, Ito M, Croner R, Kessler H, Kuzu MA. Standardization of the Definition and Surgical Management of Splenic Flexure Carcinoma by an International Expert Consensus Using the Delphi Technique: Room for Improvement? Dis Colon Rectum 2023; 66:805-815. [PMID: 36716403 DOI: 10.1097/dcr.0000000000002692] [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: 02/01/2023]
Abstract
BACKGROUND Surgical management of splenic flexure carcinoma remains controversial. OBJECTIVE This study aimed to establish an expert international consensus on splenic flexure carcinoma management. DESIGN A 3-round online-based Delphi study was conducted between September 2020 and April 2021. SETTING The first round included 18 experts from 12 different countries. For the second and third rounds, each expert in the first round was asked to invite 2 more colorectal surgeons (n = 47). Out of 47 invited experts, 89% (n = 42) participated in the second and third rounds of the consensus. INTERVENTIONS A total of 35 questions were created and sent via the online questionnaire tool. MAIN OUTCOME MEASURES Levels of recommendation based on voting concordance were graded as follows: more than 75% agreement was defined as strong, between 50% and 75% as moderate, and below 50% as weak. RESULTS There was moderate consensus on the definition of splenic flexure (55%) as 10 cm from either side where the distal transverse colon turns into the proximal descending colon. Also, experts recommended an abdominopelvic CT scan plus intraoperative exploration (moderate consensus, 72%) for tumor localization and cancer registry. Segmental colectomy was the preferred technique for the management of splenic flexure carcinoma in the elective setting (72%). Moderate consensus was achieved on the technique of complete mesocolic excision and central vascular ligation principles for splenic flexure carcinoma (74%). Only strong consensus was achieved on the surgical approach for minimally invasive surgery (88%). LIMITATIONS Subjective decisions are based on individual expert clinical experience and not evidence based. CONCLUSIONS This is the first internationally conducted Delphi consensus study regarding splenic flexure carcinoma. The definition of splenic flexure remains ambiguous. To more effectively compare oncologic outcomes among different cancer registries, guidelines need to be developed to standardize each domain and avoid arbitrary definitions. See Video Abstract at http://links.lww.com/DCR/C143 . ESTANDARIZACIN DE LA DEFINICIN Y MANEJO QUIRRGICO DEL CARCINOMA DE NGULO ESPLNICO ESTABLECIDO POR UN CONSENSO INTERNACIONAL DE EXPERTOS UTILIZANDO LA TCNICA DELPHI ESPACIO PARA MEJORAR ANTECEDENTES:El tratamiento quirúrgico del cáncer de ángulo esplénico sigue siendo controvertido.OBJETIVO:Establecer un consenso internacional de expertos sobre el manejo del cáncer del ángulo esplénico.DISEÑO:Se condujo un estudio Delphi en línea de 3 rondas entre septiembre de 2020 y febrero de 2021.ESCENARIO:La primera ronda incluyó a 18 expertos de 12 países distintos. Para la segunda y tercera rondas, a cada experto de la primera ronda se le pidió que invitara a 2 cirujanos colorrectales más de su región (n = 47). De los 47 expertos invitados, el 89% (n = 42) participó en la segunda y tercera ronda del consenso.INTERVENCIONES:Se crearon y enviaron un total de 35 preguntas a través de la herramienta de cuestionario en línea.PRINCIPALES MEDIDAS DE RESULTADO:Los niveles de recomendación basados en la concordancia de votos fueron jerarquizados de la siguiente manera: más del 75% de acuerdo se definió como fuerte, entre 50 y 75% como moderado y por debajo del 50% como débil.RESULTADOS:Hubo un consenso moderado sobre la definición de ángulo esplénico (55%) como 10 cm desde cualquier lado donde el colon transverso distal se convierte en el colon descendente proximal. Así también, los expertos recomendaron la tomografía computarizada abdominopélvica más la exploración intraoperatoria (consenso moderado, 72%) para la localización del tumor y el registro del ángulo esplénico. La colectomía segmentaria fue la técnica preferida para el tratamiento del cáncer de ángulo esplénico en el caso de ser electivo (72%). Se logró un consenso moderado sobre la técnica de escisión completa del mesocolon y los principios de ligadura vascular a nivel central para el cáncer de ángulo esplénico (74%). Solo se logró un fuerte consenso sobre el abordaje quirúrgico para la cirugía mínimamente invasiva (88%).LIMITACIONES:Decisiones subjetivas basadas en la experiencia clínica de expertos individuales y no basadas en evidencia.CONCLUSIONES:Este es el primer estudio internacional de consenso Delphi realizado sobre el cáncer de ángulo esplénico. Si bien encontramos un consenso moderado sobre las modalidades de diagnóstico preoperatorio y el manejo quirúrgico, la definición de ángulo esplénico sigue siendo ambigua. Para comparar de manera más efectiva los resultados oncológicos entre diferentes registros de cáncer, se deben desarrollar pautas para estandarizar cada dominio y evitar definiciones arbitrarias. Consulte Video Resumen en http://links.lww.com/DCR/C143 . (Traducción-Dr. Osvaldo Gauto ).
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Affiliation(s)
- Cigdem Benlice
- Department of General Surgery, School of Medicine; Ankara University, Ankara, Turkey
| | - Amjad Parvaiz
- Department of General Surgery, Champalimaud Cancer Foundation, Lisbon, Portugal
| | - Bilgi Baca
- Department of General Surgery, School of Medicine; Acibadem Mehmet Ali Aydinlar, Istanbul, Turkey
| | | | - Danilo Miskovic
- Department of General Surgery, St Marks Hospital, United Kingdom
| | - Luca Stocchi
- Division of Colorectal Surgery, Mayo Clinic, Jacksonville, Florida
| | - Scott Steele
- Department of Colorectal Surgery, DDSI, Celeveland Clinic, Cleveland, Ohio
| | - Seon-Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Torbjörn Holm
- Division of Coloproctology, Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of General Surgery, IRCCS Humanitas Research Hospital, Rozzano Milan, Italy
| | - Ismail Gogenur
- Department of Clinical Medicine, Center for Surgical Science, University of Copenhagen, Copenhagen, Denmark
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital and University of Paris, France
| | - Hirotoshi Hasegawa
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
| | - Alexey Karachun
- Department of Abdominal Surgical Oncology, N.N. Petrov National Medical Research Center of Oncology, Saint Petersburg, Russia
| | - Juan C Patron Uriburu
- Department of General Surgery, Coloproctology Service, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Masaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East Chiba, Japan
| | - Roland Croner
- Department of General, Abdominal and Vascular Surgery, University Hospital, Magdeburg, Germany
| | - Hermann Kessler
- Department of Colorectal Surgery, DDSI, Celeveland Clinic, Cleveland, Ohio
| | - Mehmet Ayhan Kuzu
- Department of General Surgery, School of Medicine; Ankara University, Ankara, Turkey
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19
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Carey-Love A, Dassel M, Kessler H, Luna Russo M. Anatomical and Surgical Considerations for Ileocolic Endometriosis. J Minim Invasive Gynecol 2023; 30:445. [PMID: 36934878 DOI: 10.1016/j.jmig.2023.03.007] [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: 02/14/2023] [Revised: 03/05/2023] [Accepted: 03/10/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE We aim to review the incidence, location, and management of bowel endometriosis and demonstrate relevant surgical principles while emphasizing anatomic considerations for minimally invasive resection of ileocolic lesions. DESIGN This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with symptomatic terminal ileum endometriosis and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anatomy. Institutional review board approval was not required. SETTING This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologic and colorectal surgeons. PATIENTS OR PARTICIPANTS The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain and was found to have a small bowel obstruction from a 3-centimeter lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical intervention. Pelvic magnetic resonance imaging was performed for preoperative planning. INTERVENTION Laparoscopic ileocolic resection is performed using a medial-to-lateral approach for excision of a symptomatic 3-centimeter ileocecal endometrioma. The following techniques are highlighted: (1) Evaluation of the entire small bowel starting at the ligament of Treitz (2) Entry into the retroperitoneum below the ileum with cranial and caudal dissection (3) Mobilization of the ascending colon to the level of the falciform ligament (4) Extension of the umbilical incision to perform an extracorporeal ileocecal resection and anastomosis CONCLUSION: The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon [1]. Lesions can be either superficial or deeply infiltrative and can lead to a range of symptoms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention.
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Affiliation(s)
- Angelina Carey-Love
- Women's Health Institute, Division of Minimally Invasive Gynecologic Surgery (Drs. Carey-Love, Dassel, Russo).
| | - Mark Dassel
- Women's Health Institute, Division of Minimally Invasive Gynecologic Surgery (Drs. Carey-Love, Dassel, Russo)
| | - Hermann Kessler
- Digestive Disease and Surgery Institute Department of Colorectal Surgery (Dr. Kessler), Cleveland Clinic, Cleveland, Ohio
| | - Miguel Luna Russo
- Women's Health Institute, Division of Minimally Invasive Gynecologic Surgery (Drs. Carey-Love, Dassel, Russo)
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20
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Connelly TM, Clancy C, Cheong JY, Jia X, Bhama AR, Lightner A, Kessler H, Valente M, Holubar SD. What is the real morbidity after emergency colectomy for Crohn's disease? A propensity score matched study. Tech Coloproctol 2023; 27:309-315. [PMID: 36376698 DOI: 10.1007/s10151-022-02727-5] [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: 09/23/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the inflammatory bowel disease literature, emergency surgery for Crohn's disease (CD) is associated with worse postoperative outcomes as compared to elective surgery. Previous studies have compared heterogeneous groups only. We hypothesized that this association would be lost after matched analysis. We aimed to compare matched CD patients undergoing elective vs emergency surgery. METHODS The National Surgical Quality Improvement database (01/2005-12/2019) was utilized to identify adult CD surgical patients. Univariate and conditional logistic regression models were used to analyze unmatched and matched cohorts. Propensity-score matching was performed to match emergency to non-emergency patients 1:1. Our primary outcome was a composite of any complication. Our secondary endpoints were hospital readmission, unplanned reoperation and 30-day morbidity and mortality. RESULTS In the unmatched analyses (n = 12,181/95.28% elective and n = 603/4.72% emergency) of Crohn's patients undergoing colectomy, 20% of elective and 42% of emergency patients experienced a complication (p < 0.001). Over 20 outcomes measured including length of stay (LOS), readmission, infections and respiratory, cardiovascular and renal complications, were worse in the emergency cohort. In the matched analyses (n = 400 emergency/400 elective patients) only the categories of any complication (OR 1.44, 1.06-1.96 95% CI, p = 0.02), any surgical site infection (SSI, OR 1.53, 1.07-2.19 95% CI, p = 0.02), superficial SSI (OR 2.25, 1.14-4.44 95% CI, p = 0.02), organ space SSI (1.58 OR 1.04-2.4 95% CI, p = 0.03), unplanned intubation (OR 5.0, 1.45-17.27 95% CI, p = 0.01), ventilation > 48 h (OR 9.0, 1.4-38.79 95% CI, p = 0.003) and septic shock (OR 4.5, 1.86-10.9 95% CI, p < 0.001) were higher in the emergency cohort. CONCLUSIONS Matching CD patients resulted in a loss of the observed increase in cardiovascular and renal complications, reoperation and LOS following emergency surgery; however, SSIs and respiratory complications remained increased despite matching.
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Affiliation(s)
- T M Connelly
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave/A 30, Cleveland, OH, 44195, USA
| | - C Clancy
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave/A 30, Cleveland, OH, 44195, USA
| | - J Y Cheong
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave/A 30, Cleveland, OH, 44195, USA
| | - X Jia
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave/A 30, Cleveland, OH, 44195, USA
| | - A R Bhama
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave/A 30, Cleveland, OH, 44195, USA
| | - A Lightner
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave/A 30, Cleveland, OH, 44195, USA
| | - H Kessler
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave/A 30, Cleveland, OH, 44195, USA
| | - M Valente
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave/A 30, Cleveland, OH, 44195, USA
| | - S D Holubar
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave/A 30, Cleveland, OH, 44195, USA.
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21
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Hummel EM, Piovesan K, Berg F, Herpertz S, Kessler H, Kumsta R, Moser DA. Mitochondrial DNA as a marker for treatment-response in post-traumatic stress disorder. Psychoneuroendocrinology 2023; 148:105993. [PMID: 36462294 DOI: 10.1016/j.psyneuen.2022.105993] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 09/09/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
Abstract
Post-traumatic stress disorder (PTSD) is a serious mental health condition thought to be mediated by a dysregulated stress response system. Stress, especially chronic stress, affects mitochondrial activity and their efficiency in duplicating their genomes. Human cells contain numerous mitochondria that harbor multiple copies of their own genome, which consist of a mixture of wild type and variant mtDNA - a condition known as mitochondrial heteroplasmy. Number of mitochondrial genomes in a cell and the degree of heteroplasmy may serve as an indicator of mitochondrial allostatic load. Changes in mtDNA copy number and the proportion of variant mtDNA may be related to mental disorders and symptom severity, suggesting an involvement of mitochondrial dysfunction also in PTSD. Therefore, we examined number and composition of mitochondrial DNA before and after six weeks of inpatient psychotherapy treatment in a cohort of 60 female PTSD patients. We extracted DNA from isolated monocytes before and after inpatient treatment and quantified cellular mtDNA using multiplex qPCR. We hypothesized that treatment would lead to changes in cellular mtDNA levels and that change in mtDNA level would be associated with PTSD symptom severity and treatment response. It could be shown that mtDNA copy number and the ratio of variant mtDNA decreased during therapy, however, this change did not correlate with treatment response. Our results suggest that inpatient treatment can reduce signs of mitochondrial allostatic load, which could have beneficial effects on mental health. The quantification of mtDNA and the determination of cellular heteroplasmy could represent valuable biomarkers for the molecular characterization of mental disorders in the future.
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Affiliation(s)
- E M Hummel
- Department of Genetic Psychology, Faculty of Psychology, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany.
| | - K Piovesan
- Department of Genetic Psychology, Faculty of Psychology, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany
| | - F Berg
- Department of Genetic Psychology, Faculty of Psychology, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany
| | - S Herpertz
- Department of Psychosomatic Medicine and Psychotherapy, LWL-University Hospital, Ruhr University Bochum, Germany
| | - H Kessler
- Department of Psychosomatic Medicine and Psychotherapy, LWL-University Hospital, Ruhr University Bochum, Germany; Department of Psychosomatic Medicine and Psychotherapy, Fulda Hospital, University Medicine Marburg Campus Fulda, Fulda, Germany
| | - R Kumsta
- Department of Genetic Psychology, Faculty of Psychology, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany; Department of Behavioural and Cognitive Sciences, Laboratory for Stress and Gene-Environment nterplay, University of Luxemburg, Porte des Sciences, L-4366 Esch-sur-Alzette, Luxemburg
| | - D A Moser
- Department of Genetic Psychology, Faculty of Psychology, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany.
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22
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Kessler H, Cheong JY, Connelly TM. How to Do It: Laparoscopic Total Abdominal Colectomy with Complete Mesocolic Excision (CME) for Transverse Colon Cancer in Ulcerative Colitis. J Gastrointest Surg 2022; 27:636-639. [PMID: 36526828 DOI: 10.1007/s11605-022-05526-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/02/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Ulcerative colitis (UC) is a chronic mucosal inflammatory bowel disease of the colon and rectum. After 10 years of having the disease, there is a significant risk of dysplasia or cancer in the affected colon and rectum, and because of the often aggressive biology of these tumors, frequent endoscopic surveillance is warranted. Over a third of patients with UC will ultimately require an operation, and although for specific cases alternative operations can be pursued, most patients prefer an ileal pouch-anal anastomosis (IPAA) with J-pouch construction. CASE A staged IPAA removes the affected colon and rectum treating UC and also restores intestinal continuity. However, the standard colectomy for UC includes low ligations of the main colonic vascular pedicle branches (ileocolic, right colic, middle colic and inferior mesenteric) that does not address a proper oncologic operation. A high ligation of the named vessels as well as a proper resection of the affected colon with its mesentery and lymph node package are needed to treat colon cancer. Analogous to a total mesorectal exicision for rectal cancer, a more radical procedure to remove the tumor and lymph node packet for colon cancer is described as a complete mesocolic exision (CME) in efforts to increase disease free survival. DISCUSSION We demonstrate a laparoscopic subtotal colectomy for UC, with an oncologic complete mesocolic excision for a left transverse colon carcinoma in the setting of chronic mucosal inflammation secondary to chronic UC as the first procedure in a 3-staged IPAA. In the video, it is also demonstrated how the lymph node dissection is extended towards the greater gastric curvature and comprising omentum and gastrocolic ligament. There were no postoperative complications in the 44-year old male patient.
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Affiliation(s)
- Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Ju Yong Cheong
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tara M Connelly
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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23
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Carey-Love A, Dassel M, Kessler H, Luna-Russo M. Anatomical and Surgical Considerations for Ileocolic Endometriosis. J Minim Invasive Gynecol 2022. [DOI: 10.1016/j.jmig.2022.09.533] [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] [Indexed: 11/27/2022]
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24
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Lincango EP, Connelly TM, Cheong JY, Kessler H. An incidental infiltrating colonic lesion found during colonoscopy in a woman in her 30s. ANZ J Surg 2022; 93:1050-1051. [PMID: 36239272 DOI: 10.1111/ans.18093] [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: 08/10/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Eddy P Lincango
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Tara M Connelly
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Ju Yong Cheong
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
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25
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Connelly TM, Clancy C, Duraes LC, Cheong JY, Cengiz B, Jia X, Hull T, Holubar SD, Steele SR, Kessler H. Laparoscopic surgery for complex Crohn's disease: perioperative and long-term results from a propensity matched cohort. Int J Colorectal Dis 2022; 37:1885-1891. [PMID: 35869990 DOI: 10.1007/s00384-022-04218-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Laparoscopic surgery for complicated Crohn's (CD) is often technically challenging. Previous studies are limited by the comparison of heterogeneous cohorts of patients undergoing laparoscopic vs open surgery. We aimed to compare perioperative and long-term outcomes of matched patients undergoing laparoscopic and open colonic and ileocolonic resection. Primary outcomes were operative time, blood loss, and complications. Long-term outcomes were subsequent intraabdominal CD surgery, incisional hernia repair, and stoma reversal rates. METHODS Laparoscopic and open CD patients were 1:1 propensity score matched on age, body mass index, sex, indication, ASA grade, prior abdominal surgery, and postoperative Crohn's medication use based on the laparoscopic approach. RESULTS A total of 906 patients underwent surgery for complex CD. After propensity matching, 386 were analyzed (193 open/193 lap, 51.3% male, mean age 33.9 + / - 12.6). Mean follow-up was 9.8 (range 7.9-12.1) years. Length of stay [(LOS) 6 (4, 8) vs 8 (5, 11) days, p < 0.001] and operative time [154 (110, 216) vs 176 (126, 239) min, p = 0.03] were shorter in the laparoscopic group. There was no difference in other complications or mortality. After adjusting for postoperative medications, no association was found between operative approach and subsequent intra-abdominal operation or incisional hernia repair. Laparoscopic patients were less likely to have postoperative sepsis [OR 0.40 (0.18, 0.91), p = 0.03]. CONCLUSION In the setting of complicated Crohn's, in matched cohorts, laparoscopic surgery is associated with reduced operative times and LOS. Mortality, reoperation, and symptomatic hernia rates were equivalent to open surgery. Patients undergoing laparoscopic surgery are less likely to experience postoperative sepsis.
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Affiliation(s)
- Tara M Connelly
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Cillian Clancy
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Leonardo C Duraes
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Ju Yong Cheong
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Bora Cengiz
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Xue Jia
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Tracy Hull
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Stefan D Holubar
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Scott R Steele
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Hermann Kessler
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA.
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Connelly TM, Clancy C, Steele SR, Kessler H. Lymph node recurrence after right colon resection for cancer: evidence for the utilisation of complete mesocolic excision. BMJ Case Rep 2022; 15:15/5/e247904. [PMID: 35550325 DOI: 10.1136/bcr-2021-247904] [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] [Indexed: 11/04/2022] Open
Abstract
Complete mesocolic excision (CME) of colon cancer is a resection performed along embryological planes to include the completely intact mesentery surrounding the tumour with a high central vascular ligation. The aim is to remove all lymph nodes draining the cancer. Proponents of the technique cite the significantly decreased local recurrence and improved 5-year survival rates associated with CME versus conventional colectomy. Although increasingly performed in many centres, it has not yet gained widespread acceptance as it is technically more challenging and can incur an increased bleeding risk. A man in his 80s underwent a conventional right hemicolectomy for a pT4aN2aM0 ascending colon cancer at another institution. This was followed by chemotherapy. He presented to our institution 2 years later with an isolated 3.7×3.2 cm mesenteric tumour adjacent to his anastomosis. There was no intraluminal recurrence. He then underwent a repeat extended right colectomy with CME. Pathology confirmed lymph node recurrence. His case demonstrates the importance of CME in reducing carcinoma recurrence risk.
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Affiliation(s)
| | - Cillian Clancy
- Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
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27
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Duraes LC, Steele SR, Valente MA, Lavryk OA, Connelly TM, Kessler H. Right colon, left colon, and rectal cancer have different oncologic and quality of life outcomes. Int J Colorectal Dis 2022; 37:939-948. [PMID: 35312830 DOI: 10.1007/s00384-022-04121-x] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Colorectal cancer patients are commonly considered a single entity in outcomes studies. This is particularly true for quality of life (QOL) studies. This study aims to compare oncologic and QOL outcomes between right colon, left colon, and rectal cancer in patients operated on in a single high-volume institution. METHODS A prospectively maintained database was queried to identify patients with pathological stages I-III colorectal adenocarcinoma electively operated on with curative intent between 2000 and 2010. Patient characteristics, perioperative and oncologic outcomes, and QOL were compared according to cancer location. RESULTS Two-thousand sixty-five (606 right colon cancer [RCC], 366 left colon cancer [LCC], and 1093 rectal cancer [RC]) patients met the inclusion criteria. LCC had better overall survival (OS) and disease-free survival (DFS) in the non-adjusted analysis (p < 0.001) and better OS in multivariate analysis adjusted by age, gender, ASA, chemotherapy, and pathological stage (p = 0.024). Although RCC had worse OS and DFS in non-adjusted survival analysis than LCC and RC, when adjusted for the factors above, RCC had better survival outcomes than RC, but not LCC. COX regression analysis showed age (p < 0.001), gender (p = 0.016), ASA (p < 0.001), pathological stage (p < 0.001), adjuvant chemotherapy (p = 0.043), and cancer location (p = 0.024) were independently associated with OS. Age (p < 0.001), gender (p = 0.030), ASA (p = 0.004), and pathological stage (p < 0.001) were independently associated with DFS. Patients with RC reported more sexual dysfunction and work restrictions than colon cancers (p = 0.015 and p < 0.001, respectively). CONCLUSION In an adjusted multivariate analysis, colon cancers demonstrated better survival outcomes when compared to rectal cancers.
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Affiliation(s)
- Leonardo C Duraes
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, A3044122, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, A3044122, USA
| | - Michael A Valente
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, A3044122, USA
| | - Olga A Lavryk
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, A3044122, USA
| | - Tara M Connelly
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, A3044122, USA
| | - Hermann Kessler
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, A3044122, USA.
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Connelly TM, Clancy C, Hu S, Steele SR, Kessler H. A Low rectal GIST. BMJ Case Rep 2022; 15:e248505. [PMID: 35288433 PMCID: PMC8921934 DOI: 10.1136/bcr-2021-248505] [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] [Accepted: 02/11/2022] [Indexed: 11/04/2022] Open
Abstract
A man in his 70s presented with narrowing of his stool calibre and a palpable mass on rectal examination. Colonoscopy revealed a submucosal bulge without a mucosal lesion. CT and MRI demonstrated an 8×5.4×7 cm mass in lower rectum. Biopsy of the mass confirmed a rectal gastrointestinal stromal tumour (GIST). It was moderately sensitive to neoadjuvant imatinib and radiotherapy, which slightly downsized the tumour. He required abdominal perineal resection with curative intent. Uncommonly found in the rectum, when located here, GISTs are typically aggressive and are a rare cause of stool calibre narrowing. Rectal GISTs should be considered in patients presenting with this symptom.
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Affiliation(s)
- Tara M Connelly
- Colorectal Surgery, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, USA
| | - Cillian Clancy
- Colorectal Surgery, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, USA
| | - Shaomin Hu
- Department of GI/Liver Pathology, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, USA
| | - Scott R Steele
- Colorectal Surgery, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, USA
| | - Hermann Kessler
- Colorectal Surgery, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, USA
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Turan A, Cohen B, Elsharkawy H, Maheshwari K, Soliman LM, Babazade R, Ayad S, Hassan M, Elkassabany N, Essber HA, Kessler H, Mao G, Esa WAS, Sessler DI. Transversus abdominis plane block with liposomal bupivacaine versus continuous epidural analgesia for major abdominal surgery: The EXPLANE randomized trial. J Clin Anesth 2021; 77:110640. [PMID: 34969004 DOI: 10.1016/j.jclinane.2021.110640] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Compare transversus abdominis plane (TAP) blocks with liposomal bupivacaine were to epidural analgesia for pain at rest and opioid consumption in patients recovering from abdominal surgery. BACKGROUND ERAS pathways suggest TAP blocks in preference to epidural analgesia for abdominal surgery. However, the relative efficacies of TAP blocks and epidural analgesia remains unknown. METHODS Patients having major abdominal surgery were enrolled at six sites and randomly assigned 1:1 to thoracic epidural analgesia or bilateral/4-quadrant TAP blocks with liposomal bupivacaine. Intravenous opioids were used as needed. Non-inferiority margins were a priori set at 1 point on an 11-point pain numeric rating scale for pain at rest and at a 25% increase in postoperative opioid consumption. RESULTS Enrollment was stopped per protocol at 3rd interim analysis after crossing an a priori futility boundary. 498 patients were analyzed (255 had TAP blocks and 243 had epidurals). Pain scores at rest in patients assigned to TAP blocks were significantly non-inferior to those given epidurals, with an estimated difference of 0.09 points (CI: -0.12, 0.30; noninferiority P < 0.001). Opioid consumption during the initial 3 postoperative days in TAP patients was not non-inferior to epidurals, with an estimated ratio of geometric means of 1.37 (CI: 1.05, 1.79; non-inferiority P = 0.754). However, the absolute difference was only 21 mg morphine equivalents over the 3 days. Patients with epidurals were more likely to experience mean arterial pressures <65 mmHg than those given TAP blocks: 48% versus 31%, P = 0.006. CONCLUSION Pain scores at rest during the initial three days after major abdominal surgery were similar. Patients assigned to TAP blocks required more opioid then epidural patients but had less hypotension. Clinicians should reconsider epidural analgesia in patients at risk from hypotension. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02996227.
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Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America.
| | - Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, United States of America; Division of Anesthesiology, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hesham Elsharkawy
- Department of Outcomes Research, Cleveland Clinic, United States of America; Pain Center, Anesthesiology Department, MetroHealth, Case Western Reserve University, OH, United States of America
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Loran Mounir Soliman
- Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Rovnat Babazade
- Department of Anesthesiology, University of Texas Medical Branch of Galveston, TX, United States of America
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Manal Hassan
- Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Nabil Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, United States of America
| | - Hani A Essber
- Department of Outcomes Research, Cleveland Clinic, United States of America
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, United States of America
| | - Guangmei Mao
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic
| | - Wael Ali Sakr Esa
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, United States of America
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Ordenana C, Dalla Pozza E, Rampazzo A, Said S, McBride J, Kessler H, Bassiri Gharb B. Wide posterior gluteal-thigh propeller flap for reconstruction of perineal defects. Microsurgery 2020; 41:146-156. [PMID: 33030284 DOI: 10.1002/micr.30666] [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: 01/05/2020] [Revised: 07/11/2020] [Accepted: 09/18/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION With increasing popularity of minimally invasive approaches to abdominoperineal resection (APR), thigh-based flaps are becoming the preferred option for reconstruction. The gluteal-thigh flap provides sufficient bulk, albeit with a high complication rate. We reevaluated the vascularization and design of the gluteal-thigh flap. The purpose of this study is to highlight the importance of the vascularization of the posterior thigh skin by the descending branch of the inferior gluteal artery (IGA) and the profunda femoris artery (PFA) perforators to design a more reliable and versatile gluteal thigh flap. This flap is indicated in selected cases in which use of vertical rectus abdominis musculocutaneous flap is not feasible. METHODS Eleven fresh cadavers were used. The course, distribution, and diameter of IGA and PFA perforators were recorded. A wide posterior gluteal-thigh propeller flap (WPGTPF) was designed including the distance between the ischiatic tuberosity and greater trochanter; and extending it to within 8 cm of the popliteal fossa to improve flap reliability. Ten patients (mean age of 58.7 ± 10.6 years) underwent APR due to anal cancer (2) and rectal cancer (8); the approach was open in 3, laparoscopic in 6, and robotic in 1. All 10 patients received unilateral flap with a width of 12 ± 3.3 cm and surface of 405.5 ± 175.9 cm2 . RESULTS The descending branch of the IGA was dominant in 72.7% of the specimens. In 22.7% of the specimens, the pedicle of the flap derived from the first or second PFA perforators. In one case, there was a double vascularization. Descending branch of the IGA was mapped at 46 ± 7.96 mm on the X-axis (horizontal line from the ischial tuberosity [IT] to the greater trochanter) and -12.1 ± 17.9 mm on the Y-axis (vertical line from the IT to the Medial Femoral condyle). Its average caliber measured 2.18 ± 0.3 mm. The first and second PFA perforators were located at 101.6 ± 17.9 mm and 104.5 ± 15.5 mm on the X-axis; 35.9 ± 27.1 mm and 89.2 ± 37.6 mm on the Y-axis. Their average diameters were 1.84 ± 0.41 mm and 1.48 ± 0.3 mm. In two cases, the flap was based on the first PFA perforator, the rest were on the descending branch of the IGA. Neither complete nor partial flap necrosis was observed. One patient developed coccyx osteomyelitis treated and resolved with bone debridement and one patient developed a seroma of the lateral thigh that was treated conservatively. Three patients underwent a debulking procedure by a combination of liposuction and resection to improve the gluteal symmetry. All ten flaps survived completely. CONCLUSIONS Harvest of a wide flap that includes the PFA perforators and implementation of the propeller design increase the survival and versatility of the flap.
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Affiliation(s)
- Carlos Ordenana
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Edoardo Dalla Pozza
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sayf Said
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer McBride
- Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bahar Bassiri Gharb
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Williams J, Stocchi L, Aiello A, Bhama A, Kessler H, Gorgun E, Delaney CP, Steele S, Valente M. No need to watch the clock: persistence during laparoscopic sigmoidectomy for diverticular disease. Surg Endosc 2020; 35:2823-2830. [PMID: 32556770 DOI: 10.1007/s00464-020-07717-y] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 06/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Laparoscopic sigmoidectomy is the preferred approach in the elective surgical management of diverticulitis. However, it is unclear if the benefits of laparoscopy persist when operative times are prolonged. We aimed to investigate if the recovery benefits associated with laparoscopy are retained when operative times are long. METHODS A retrospective review of a prospectively maintained database of patients who underwent elective laparoscopic sigmoidectomy from 2010-2015 at a single academic tertiary institution was performed. Operative times among laparoscopic completed cases were divided into quartiles, and patient outcomes were compared between the groups. RESULTS A total of 466 patients (median age: 58 ± 11.6 years, 58% females) underwent sigmoidectomy: 430 completed laparoscopically and 36 (7.7%) converted. Median operative time in laparoscopically completed cases was 188 min (IQR 154-230). There were no differences in morbidity (P = 0.52) or readmission rates (P = 0.22) among the quartiles. The 2nd and 4th operative time quartiles were associated with significantly longer length of stay (LOS) when compared to the fastest quartile (P = 0.003 and P = 0.002, respectively), but there was no increase in LOS as operative times progressed between the 2nd, 3rd, and 4th quartiles. LOS after conversion was longer but did not reach statistical significance when compared to laparoscopically completed operations in the longest quartile (5.0 vs 6.5 days, P = 0.075) CONCLUSIONS: Our data do not support preemptive conversion of laparoscopic sigmoidectomy to avoid prolonged operative times. As long as progress is safely being made, surgeons are justified to continue pursuing laparoscopic completion.
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Affiliation(s)
- Jennifer Williams
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Alexandra Aiello
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Anuradha Bhama
- Division of Colorectal Surgery, Department of Surgery, Rush University, Chicago, IL, USA
| | - Hermann Kessler
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Emre Gorgun
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Conor P Delaney
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Scott Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Michael Valente
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA.
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Rickenbacher A, Watson J, Horisberger K, Töpfer A, Weber A, Kessler H, Turina M. Direct intraoperative assessment of total mesorectal excision specimens by expert pathologists in patients with very low rectal cancer prevents unnecessary abdominoperineal resections. Int J Colorectal Dis 2020; 35:755-758. [PMID: 31980873 DOI: 10.1007/s00384-020-03514-0] [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] [Accepted: 01/20/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE In patients with low rectal cancer, the intraoperative assessment of sufficient distal resection margins can be challenging. The assessment determines whether reconstruction can be performed or whether permanent colostomy is required. The goal of the present study was to evaluate intraoperative assessment of the total mesorectal excision (TME) specimen during an interruption of the operation. METHODS The intraoperative strategy of eight patients with low rectal cancer was evaluated. In all cases, intraoperative pathological assessment of the TME specimen by an expert pathologist together with the surgeon was performed. Assessment of the distance of the tumor to the resection margin was measured macroscopically as well as microscopically. RESULTS All patients underwent neoadjuvant chemoradiation. The tumor was located at an average 4.8 ± 1.4 cm from the anal verge. In all cases, preoperative MRI revealed mrT3 tumors. The intraoperative assessment showed a median distal resection margin of 10 mm (2-15 mm). In six patients, sufficient margins allowed for reconstruction while in two patients APR was needed. In three patients (37.5%), the pathological assessment changed the operative strategy: In one patient APR could be avoided while two patients required APR instead of the anticipated TME. CONCLUSION The intraoperative assessment of the TME specimen by an expert pathologist together with the surgeon is a valuable tool to avoid unnecessary APR or R1 resections. We therefore suggest routine intraoperative pathological assessment in all operations for borderline low rectal cancers.
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Affiliation(s)
- Andreas Rickenbacher
- Department of Surgery and Transplantation, University Hospital Zürich, Raemistrasse 100, CH-8091, Zürich, Switzerland
| | - Jennifer Watson
- Department of Surgery and Transplantation, University Hospital Zürich, Raemistrasse 100, CH-8091, Zürich, Switzerland
| | - Karoline Horisberger
- Department of Surgery and Transplantation, University Hospital Zürich, Raemistrasse 100, CH-8091, Zürich, Switzerland
| | - Antonia Töpfer
- Department of Pathology, University Hospital Zürich, CH-8091, Zürich, Switzerland
| | - Achim Weber
- Department of Pathology, University Hospital Zürich, CH-8091, Zürich, Switzerland
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Matthias Turina
- Department of Surgery and Transplantation, University Hospital Zürich, Raemistrasse 100, CH-8091, Zürich, Switzerland.
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Novello M, Stocchi L, Steele SR, Holubar SD, Duraes LC, Kessler H, Shawki S, Hull LT. Case-matched Comparison of Postoperative Outcomes Following Surgery for Inflammatory Bowel Disease After Exposure to Vedolizumab vs Other Biologics. J Crohns Colitis 2020; 14:185-191. [PMID: 31328222 DOI: 10.1093/ecco-jcc/jjz129] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM The effects of vedolizumab [VEDO] exposure on perioperative outcomes following surgery for inflammatory bowel disease [IBD] remain controversial. The aim of our study was to compare postoperative morbidity of IBD surgery following treatment with VEDO vs other biologics or no biologics. METHODS An institutional review board-approved, prospectively collected database was queried to identify all patients undergoing abdominal surgery for IBD between August 2012 and May 2017. The impact of VEDO within 12 weeks preoperatively on postoperative morbidity was initially assessed with univariate and multivariable analyses on all patients. A case-matched analysis was then carried out comparing patients exposed to VEDO vs other biologic agents, based on gender, age ± 5 years, diagnosis, date of surgery ± 2 years, and surgical procedure. RESULTS Out of 980 patients, 141 received VEDO. The majority of patients [59%] underwent surgery involving end or diverting ostomy creation. The initial multivariate analysis conducted on all patients indicated that VEDO use was independently associated with increased overall morbidity [p <0.001], but not infectious morbidity [p = 0.30]. However, the case-matched comparison of 95 VEDO-treated patients vs 95 patients treated with adalimumab or infliximab did not indicate any difference in overall morbidity [p = 0.32], infectious complications [p = 0.15], or surgical site infections [p = 0.12]. CONCLUSIONS In a study population having a high rate of surgery involving ostomy creation, the exposure to preoperative VEDO was not associated with an increased morbidity rate when compared with other biologics.
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Affiliation(s)
- M Novello
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S D Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L C Duraes
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S Shawki
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L T Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Llarena NC, Shah AB, Kessler H, Falcone T, Flyckt R. Surgical management of deep infiltrating endometriosis involving the rectosigmoid colon. Fertil Steril 2019. [DOI: 10.1016/j.fertnstert.2019.07.1298] [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] [Indexed: 11/30/2022]
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de Camargo MGM, Hull TL, Steele SR, Delaney CP, Kessler H. Laparoscopic total abdominal colectomy as first step of three-stage surgical treatment of ulcerative colitis: a systematic approach. Tech Coloproctol 2019; 23:779-780. [PMID: 31289947 DOI: 10.1007/s10151-019-02017-7] [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: 04/30/2019] [Revised: 04/30/2019] [Accepted: 06/17/2019] [Indexed: 11/26/2022]
Affiliation(s)
- M G M de Camargo
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland Clinic Main Campus, Mail Code A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - T L Hull
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland Clinic Main Campus, Mail Code A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - S R Steele
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland Clinic Main Campus, Mail Code A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - C P Delaney
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland Clinic Main Campus, Mail Code A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland Clinic Main Campus, Mail Code A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Notni J, Wurzer A, Reichart F, Maltsev O, Steiger K, Beck R, Schwaiger M, Wester HJ, Kessler H. A 68Ga-labelled PET probe for selective imaging of αvβ8-integrin. Nucl Med Biol 2019. [DOI: 10.1016/s0969-8051(19)30240-9] [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] [Indexed: 11/30/2022]
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Silva-Velazco J, Stocchi L, Valente MA, Church JM, Liska D, Gorgun E, Kalady MF, Kessler H, Steele SR, Delaney CP. The relationship between mesorectal grading and oncological outcome in rectal adenocarcinoma. Colorectal Dis 2019; 21:315-325. [PMID: 30565830 DOI: 10.1111/codi.14535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 07/25/2018] [Accepted: 10/29/2018] [Indexed: 02/08/2023]
Abstract
AIM The prognostic association between mesorectal grading and oncological outcome in patients undergoing resection for rectal adenocarcinoma is controversial. The aim of this retrospective chart review was to determine the individual impact of mesorectal grading on rectal cancer outcomes. METHOD We compared oncological outcomes in patients with complete, near-complete and incomplete mesorectum who underwent rectal excision with curative intent from 2009 to 2014 for Stage cI-III rectal adenocarcinoma. We also assessed the independent association of mesorectal grading and oncological outcome using multivariate models including other relevant variables. RESULTS Out of 505 patients (339 men, median age of 60 years), 347 (69%) underwent a restorative procedure. There were 452 (89.5%), 33 (6.5%) and 20 (4%) patients with a complete, near-complete and incomplete mesorectum, respectively. Local recurrence was seen in 2.4% (n = 12) patients after a mean follow-up of 3.1 ± 1.7 years. Unadjusted 3-year Kaplan-Meier analysis by mesorectal grade showed decreased rates of overall, disease-free and cancer-specific survival and increased rates of overall and distant recurrence with a near-complete mesorectum, while local recurrence was increased in cases of an incomplete mesorectum (all P < 0.05). On multivariate analyses, a near-complete mesorectum was independently associated with decreased cancer-specific survival (hazard ratio 0.26, 95% CI 0.1-0.7; P = 0.007). There were no associations between mesorectal grading and overall survival, disease-free survival, overall recurrence or distant recurrence (all P > 0.05). CONCLUSION Mesorectal grading is independently associated with oncological outcome. It provides unique information for optimizing surgical quality in rectal cancer.
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Affiliation(s)
- J Silva-Velazco
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - L Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - M A Valente
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - J M Church
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - D Liska
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - E Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - M F Kalady
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - S R Steele
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - C P Delaney
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 936] [Impact Index Per Article: 187.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Affiliation(s)
- Sara El Ouali
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Bo Shen
- Interventional Inflammatory Bowel Disease (i-IBD) Unit, Digestive Disease and Surgery Institute, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Fraioli R, Neubauer S, Rechenmacher F, Bosch BM, Dashnyam K, Kim JH, Perez RA, Kim HW, Gil FJ, Ginebra MP, Manero JM, Kessler H, Mas-Moruno C. Control of stem cell response and bone growth on biomaterials by fully non-peptidic integrin selective ligands. Biomater Sci 2019; 7:1281-1285. [DOI: 10.1039/c8bm01466c] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Integrin selective peptidomimetics tune stem cell behavior in vitro and improve bone formation in rat calvarial defects.
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Nieberler M, Reuning U, Kessler H, Reichart F, Weirich G, Wolff KD. Fluorescence imaging of invasive head and neck carcinoma cells with integrin αvβ6-targeting RGD-peptides: an approach to a fluorescence-assisted intraoperative cytological assessment of bony resection margins. Br J Oral Maxillofac Surg 2018; 56:972-978. [PMID: 30502043 DOI: 10.1016/j.bjoms.2018.11.003] [Citation(s) in RCA: 14] [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: 03/19/2018] [Accepted: 11/05/2018] [Indexed: 12/21/2022]
Abstract
We assessed the use of peptides containing arginylglycylaspartic acid (RGD) that target integrin αvβ6 as a potential approach for a fluorescence-assisted intraoperative cytological assessment of bony resection margins (F-AICAB) in patients who had bone-infiltrating squamous cell carcinoma (SCC) of the head and neck. This was assessed to demarcate invasive carcinoma cells that stained for αvβ6. Specimens from bony resection margins (n=362) were defined as either malignant or benign according to the results of cytological and histological examinations. Integrin αvβ6-targeting fluorescence-labelled RGD peptides were added to the cytological samples and the accuracy of the resulting signal assessed by comparing it with the cytological findings. The value of F-AICAB was evaluated to find out if it could help to improve future diagnoses, tests, and treatments. Integrin αvβ6 was strongly expressed in invasive SCC cells and qualified as a marker for bone-infiltrating carcinoma cells. It showed a high affinity to bind to invasive SCC cells and enabled swift and specific demarcation of αvβ6-stained carcinoma cells. It was also diagnostic, with a sensitivity of 100% (95% CI 81.3% to 99.3%), specificity of 98.3% (95% CI 94.4% to 99.0%), positive predictive value of 92% (95% CI 70.2% to 94.3%), and negative predictive value of 100% (95% CI 96.9% to 99.9%), compared with the cytological findings. The targeting of specific integrin subtypes with selective, synthetic ligands, adapted for multimodal imaging, is a promising new approach to diagnosis. Further studies are necessary to provide more evidence for successful clinical translation and to establish the impact on clinical procedures.
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Affiliation(s)
- M Nieberler
- Department of Oral and Maxillofacial Surgery, University Hospital rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81679 Munich, Germany.
| | - U Reuning
- Klinische Forschergruppe der Frauenklinik, University Hospital rechts der Isar, Technischen Universität München, Ismaninger Strasse 22, 81675 München, Germany
| | - H Kessler
- Institute for Advanced Study and Center for Integrated Protein Science (CIPSM), Technische Universität München, Lichtenbergstr. 4, 85747 Garching, Germany
| | - F Reichart
- Institute for Advanced Study and Center for Integrated Protein Science (CIPSM), Technische Universität München, Lichtenbergstr. 4, 85747 Garching, Germany
| | - G Weirich
- Institute of Pathology, Technische Universität München, Trogerstr. 18, 81675 Munich, Germany
| | - K-D Wolff
- Department of Oral and Maxillofacial Surgery, University Hospital rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81679 Munich, Germany
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Benlice C, Stocchi L, Sapci I, Gorgun E, Kessler H, Liska D, Steele SR, Delaney CP. Impact of the extraction-site location on wound infections after laparoscopic colorectal resection. Am J Surg 2018; 217:502-506. [PMID: 30390938 DOI: 10.1016/j.amjsurg.2018.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 07/24/2018] [Revised: 10/23/2018] [Accepted: 10/24/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND The purpose of this study was to determine the impact of the incision used for specimen extraction on wound infection during laparoscopic colorectal surgery. METHODS All patients undergoing elective laparoscopic colorectal resection in a single specialized department from 2000 to 2011 were identified from a prospectively maintained institutional database. Specific extraction-sites and other relevant factors associated with wound infection rates were evaluated with univariate and multivariate analyses. RESULTS 2801 patients underwent specimen extraction through infra-umbilical midline (N = 657), RLQ/LLQ (N = 388), stoma site (N = 58), periumbilical midline (N = 629), Pfannenstiel (N = 789) and converted midline (N = 280). The overall wound infection rate was 10% and was highest in converted midline (14.6%) and Pfannenstiel (11.4%) incisions, while the lowest rate was associated with RLQ/LLQ (N = 13, 3.3%). Independent factors associated with wound infection were increased BMI (p < 0.001), extraction site location (p = 0.006), surgical procedure (p = 0.020, particularly left-sided colectomy and total proctocolectomy), diagnosis (p < 0.001, particularly sigmoid diverticulitis and inflammatory bowel disease), intraabdominal adhesions (p = 0.033) and intrabdominal rather than pelvic procedure (p = 0.005). CONCLUSIONS A RLQ/LLQ extraction site is associated with the most reduced risk of wound infection in laparoscopic colorectal surgery.
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Affiliation(s)
- Cigdem Benlice
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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Lavryk OA, Stocchi L, Ashburn JH, Costedio M, Gorgun E, Hull TL, Kessler H, Delaney CP. Case-Matched Comparison of Long-Term Functional and Quality of Life Outcomes Following Laparoscopic Versus Open Ileal Pouch-Anal Anastomosis. World J Surg 2018; 42:3746-3754. [PMID: 29785696 DOI: 10.1007/s00268-018-4602-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Laparoscopic ileal pouch-anal anastomosis (IPAA) is associated with recovery benefits when compared with open IPAA. There is limited data on long-term quality of life and functional outcomes, which this study aimed to assess. METHODS An IRB-approved, prospectively maintained database was queried to identify patients undergoing laparoscopic IPAA (L), case-matched with open IPAA (O) based on age ± 5 years, gender, body mass index (BMI) ± 5 kg/m2, diagnosis, date of surgery ± 3 years, stapled/handsewn anastomosis, omission of diverting loop ileostomy and length of follow-up ± 3 years. We assessed functional results, dietary, social, work, sexual restrictions and the Cleveland Clinic global quality of life score (CGQoL) at 1, 2, 3, 4, 5 and 10 years postoperatively. Functional outcomes were assessed based on number of stools (day/night) and seepage protection use (day/night). Variables were evaluated with Kaplan-Meier survival curves, uni- and multivariable analyses. RESULTS Out of 4595 IPAAs, 529 patients underwent L, of whom 404 patients were well matched 1:1 to an equivalent number of O based on all criteria. Median follow-ups were 2 (0.5-17.8) versus 2.4 (0.5-22.2) years in L versus O, respectively (p = 0.18). L was associated with significantly decreased number of stools at night and less frequent pad usage at 1 year, both during the day and at night. Functional outcomes became similar during further follow-up. L was also associated with improved overall CGQoL, and energy scores at 1 year postoperatively, and decreased social restrictions for 1-2 years. There were no significant differences in quality of health, dietary, work or sexual restrictions. Laparoscopy was not associated with increased risk of pouch failure (p = 0.07) or significantly different causes of pouch failure when compared to O. CONCLUSIONS Laparoscopic and open IPAA are associated with equivalent long-term functional outcomes, quality of life and pouch survival rates. Laparoscopic technique is associated with temporary benefits lasting 1 or 2 years.
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Affiliation(s)
- Olga A Lavryk
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA.
| | - Jean H Ashburn
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Meagan Costedio
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
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Novello M, Stocchi L, Steele SR, Holubar SD, Duraes LC, Kessler H, Shawki S, Hull TL. Case-Matched Comparison of Postoperative Outcomes after Surgery for Inflammatory Bowel Disease, after Exposure to Vedolizumab vs Other Biologics. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.128] [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] [Indexed: 10/28/2022]
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Cengiz TB, Steele SR, Delaney CP, Kessler H. Laparoscopic Hartmann's reversal surgery in a complex abdomen - a video vignette. Colorectal Dis 2018; 20:648. [PMID: 29679521 DOI: 10.1111/codi.14232] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Affiliation(s)
- T B Cengiz
- Department of Colorectal Surgery-A30, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - S R Steele
- Department of Colorectal Surgery-A30, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - C P Delaney
- Department of Colorectal Surgery-A30, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - H Kessler
- Department of Colorectal Surgery-A30, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Bruchertseifer F, Bock M, Kessler H, Schwaiger M, Wester HJ, Haubner R. Synthesis and biological evaluation of a 99mTc-labelled cyclic RGD peptide for imaging the αvβ3 expression. Nuklearmedizin 2018. [DOI: 10.1055/s-0038-1623911] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Summary
Aim: The αvβ3 integrin is involved in tumour induced angiogenesis and tumour metastasis. We describe the synthesis and evaluation of a 99mTc-labelled RGD analogue for the visualisation of αvβ3 integrin expression. Methods: The linear peptides were assembled on a solid support. Cyclisation was performed under high dilution conditions. For conjugation with the chelator peptide, a water soluble carbodiimide was used. Radiolabelling was carried out due to standard procedures with high radiochemical yield and radiochemical purity. For in vivo evaluation, nude mice bearing αvβ3-positive human melanoma M21 and αv-negative human melanoma M21-L or Balb/c mice bearing αv-positive murine osteosarcoma were used. Results: Activity accumulation of 99mTc-DKCK-RGD 240 min p. i. was 1.1% ID/g in the αvβ3-positive melanoma and 0.3% ID/g in the negative control tumour. In the osteosarcoma model 2.2% ID/g was found 240 min p. i. Planar gamma camera images allowed contrasting visualisation of αvβ3-positive tumours 240 min p. i. Blocking of the tumour using the αvβ3-selective pentapeptide cyclo(-ArgGly-Asp-D-Phe-Val-) reduces activity accumulation in the tumour to background level. However, 240 min p. i. highest activity concentration was found in kidneys resulting in low tumour/kidney ratios. Metabolite analysis 240 min p. i. showed approximately 60% intact tracer in kidneys and 80% in the tumour. Only 24% intact tracer was found in blood 30 min p. i. Conclusion: 99mTc-DKCK-RGD allows imaging of αvβ3-positive tumours in mice. However, pharmacokinetics as well as metabolic stability of the tracer have to be improved for potential clinical application.
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Duraes LC, Stocchi L, Steele SR, Kalady MF, Church JM, Gorgun E, Liska D, Kessler H, Lavryk OA, Delaney CP. The Relationship Between Clavien-Dindo Morbidity Classification and Oncologic Outcomes After Colorectal Cancer Resection. Ann Surg Oncol 2017; 25:188-196. [PMID: 29116488 DOI: 10.1245/s10434-017-6142-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Limited data on the relationship between postoperative complications (POCs) after colorectal cancer resection and oncologic outcomes are available. We hypothesized that the increased severity of POCs is associated with progressively worse oncologic outcomes. METHODS Patients with pathological stages I-III colorectal adenocarcinoma undergoing elective curative resection in a single institution between 2000 and 2012 were identified from a prospectively collected database. The severity of POCs was determined using the Clavien-Dindo classification, and oncologic outcomes were assessed. RESULTS Of 2266 patients, 669 (30%) had at least one POC. POCs were not associated with pathologic stage (p = 0.58) or use of adjuvant therapy (p = 0.19). With a mean follow-up of 5.3 years, POCs were associated with decreased 5-year overall survival (OS) (60% vs. 77%, p < 0.001), disease-free survival (DFS) (53% vs. 70%, p < 0.001), cancer-specific survival (CSS) (81% vs. 87%, p < 0.001), and increased overall recurrence rates (19% vs. 15%, p = 0.008). Increasing Clavien-Dindo scores from I to IV was significantly associated with progressively decreasing OS (71, 64, 60, 22%, p < 0.001), DFS (65, 58, 51, 19%, p < 0.001), CSS (88, 77, 79, 74%, p < 0.001), and increasing recurrence rates (12, 20, 26, 18%, p = 0.002). Multivariate analysis confirmed POCs as an independent factor associated with decreased OS [hazard ratio (HR) 0.63, 95% CI 0.52-0.76], DFS (HR 0.64, 95% CI 0.54-0.76), CSS (HR 0.73, 95% CI 0.56-0.97), and increased recurrence rates (HR 1.36, 95% CI 1.02-1.80). CONCLUSIONS POCs are associated with adverse oncologic outcomes, with increasing effect with higher Clavien-Dindo score. Efforts to reduce both the incidence and severity of complications should result in improved oncologic outcomes.
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Affiliation(s)
- Leonardo C Duraes
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - James M Church
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Olga A Lavryk
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Remzi FH, Lavryk OA, Ashburn JH, Hull TL, Lavery IC, Dietz DW, Kessler H, Church JM. Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care. Colorectal Dis 2017; 19:1003-1012. [PMID: 28481467 DOI: 10.1111/codi.13699] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [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: 09/28/2016] [Accepted: 02/13/2017] [Indexed: 12/12/2022]
Abstract
AIM Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes. METHOD Patients undergoing primary IPAA at this institution were divided into three groups by date of the IPAA: those operated from 1983 to 1993, from 1994 to 2004 and from 2005 to 2015. Demographics, patient comorbidity, surgical techniques, postoperative outcomes, pouch function and quality of life were analysed. RESULTS In all, 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I, 8; II, 16; III, 31), patients tended to be sicker (higher American Society of Anesthesiologists score) and three-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. The laparoscopic technique blossomed in the last decade. 90-day postoperative morbidity by decade was 38.3% vs 50% vs 48% (P < 0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (P < 0.0001). Functional results improved, but quality of life scores did not. Pouch survival rate at 10 years was maintained (94% vs 95.2% vs 95.2%; P = 0.06). CONCLUSION IPAA is still evolving. Despite new generations of surgeons, a more accurate diagnosis, appropriate staging and the laparoscopic technique have made IPAA a safer, more effective and enduring operation.
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Affiliation(s)
- F H Remzi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland, Cleveland Clinic, Cleveland, Ohio, USA
| | - O A Lavryk
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland, Cleveland Clinic, Cleveland, Ohio, USA
| | - J H Ashburn
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland, Cleveland Clinic, Cleveland, Ohio, USA
| | - T L Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland, Cleveland Clinic, Cleveland, Ohio, USA
| | - I C Lavery
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland, Cleveland Clinic, Cleveland, Ohio, USA
| | - D W Dietz
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland, Cleveland Clinic, Cleveland, Ohio, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland, Cleveland Clinic, Cleveland, Ohio, USA
| | - J M Church
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland, Cleveland Clinic, Cleveland, Ohio, USA
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Singh A, Agrawal N, Kurada S, Lopez R, Kessler H, Philpott J, Shen B, Lashner B, Rieder F. Efficacy, Safety, and Long-term Outcome of Serial Endoscopic Balloon Dilation for Upper Gastrointestinal Crohn's Disease-associated Strictures-A Cohort Study. J Crohns Colitis 2017; 11:1044-1051. [PMID: 28881875 PMCID: PMC5881679 DOI: 10.1093/ecco-jcc/jjx078] [Citation(s) in RCA: 28] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/02/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gastric and duodenal Crohn's disease [CD]-associated strictures are rare. Evidence on endoscopic balloon dilation [EBD] of upper gastrointestinal [GI] CD strictures is limited, in particular in respect to serial dilations. METHODS Prospective short- and long-term outcome data as well as complication rates on a cohort of upper GI CD-associated stricture dilations [stomach and duodenum] were collected from 1999 to 2015. Factors linked with clinical and technical success, long-term efficacy and complication rates were investigated. RESULTS A total of 35 CD patients with symptomatic CD-associated upper GI strictures [20% gastric, 67% duodenal, 11% both; mean age at diagnosis 25 years; mean CD duration to stricture 79.9 months; median post-dilation follow-up 22.1 months] underwent a total of 96 pneumatic dilations [33 gastric and 63 duodenal]. The median maximal dilation diameter was 15 mm. Technical success was achieved in 93% and clinical success in 87%, with a complication rate of 4% per procedure. The mean time to re-dilation was 2.2 months and mean time to stricture-related surgery after first dilation was 2.8 months. There was no difference in short-term efficacy, safety, or long-term outcome between the first and any later dilation procedure in the same patient. CONCLUSIONS Pneumatic dilation of upper GI CD-associated strictures has a high rate of short-term technical and clinical success, with moderate long-term efficacy and acceptable complication rates. Serial dilations do not change the efficacy and could be a feasible option to delay or prevent surgical intervention.
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Affiliation(s)
- Amandeep Singh
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Neha Agrawal
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Satya Kurada
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Bo Shen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Bret Lashner
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH,Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH,Corresponding author: Florian Rieder, MD, Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Department of Pathobiology, Lerner Research Institute, NC22, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel: 216-445-4916; Fax 216-636-0104;
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