Total Neoadjuvant Therapy Significantly Increases Complete Clinical Response.

BACKGROUND: Increased experience with total neoadjuvant therapy for rectal cancer suggests significantly more tumor regression and increased rates of complete clinical response as measured by pathological complete response and clinical complete response. OBJECTIVE: This study aimed to assess outcomes after total neoadjuvant therapy versus standard neoadjuvant chemoradiotherapy for patients with locally advanced rectal cancer. DESIGN: This is a retrospective cohort study. SETTINGS: A database of patients with rectal cancer from 2015 to 2019 at a large integrated health care system was reviewed. PATIENTS: Demographics of the 2 groups revealed no significant difference in clinical stage or patient characteristics. Of 465 patients, 66 patients underwent total neoadjuvant therapy and 399 underwent standard neoadjuvant chemoradiotherapy. Fifty-six patients underwent consolidation chemotherapy, and 10 underwent induction chemotherapy. MAIN OUTCOME MEASURES: Complete clinical response, disease-free survival, proctectomy-free survival, and organ preservation rates were the main outcome measures. RESULTS: Complete clinical response was achieved in 36 patients (58.1%) versus 59 patients (14.8%; p < 0.001), favoring the total neoadjuvant therapy group. Three-year overall survival was similar between groups (85.6% standard neoadjuvant chemoradiotherapy versus 86.0% total neoadjuvant therapy). Three-year distant metastasis-free survival was 67.4% in the total neoadjuvant therapy group compared to 77.7% in the standard neoadjuvant chemoradiotherapy group. Three-year proctectomy-free survival was 44% in the total neoadjuvant therapy group compared to 6% in the standard neoadjuvant chemoradiotherapy group. Twenty-two patients (37.3% of complete clinical responders) in the standard neoadjuvant chemoradiotherapy group elected to pursue organ preservation, whereas 31 patients (86.1% of complete clinical responders) from the total neoadjuvant therapy group chose organ preservation. LIMITATIONS: This study is limited by its retrospective nature with a shorter follow-up of 3 years. CONCLUSIONS: Total neoadjuvant therapy for rectal cancer significantly increased complete clinical response. This allowed patients to have greater organ preservation with no significant difference in overall survival or disease control. See Video Abstract at http://links.lww.com/DCR/B934 . LA TERAPIA NEOADYUVANTE TOTAL AUMENTA SIGNIFICATIVAMENTE LA RESPUESTA CLNICA COMPLETA: ANTECEDENTES:La mayor experiencia con la terapia neoadyuvante total para el cáncer de recto sugiere una regresión tumoral significativamente mayor y mayores tasas de respuesta clínica completa, medidas por respuesta patológica completa y respuesta clínica completa.OBJETIVO:Este estudio evaluó los resultados después de la terapia neoadyuvante total versus la quimiorradioterapia neoadyuvante estándar para pacientes con cáncer de recto localmente avanzado.DISEÑO:Este es un estudio de cohorte retrospectivo.ESCENARIO:Se revisó una base de datos de pacientes con cáncer de recto de 2015 a 2019 en un sistema de salud integrado grande.PACIENTES:La demografía de los dos grupos no revela diferencias significativas en el estadio clínico o las características de los pacientes. De 465 pacientes, 66 pacientes recibieron terapia neoadyuvante total y 399 quimiorradioterapia neoadyuvante estándar. Cincuenta y seis se sometieron a quimioterapia de consolidación mientras que 10 pacientes a quimioterapia de inducción.PRINCIPALES MEDIDAS DE RESULTADO:Se midieron la respuesta clínica completa, la sobrevida libre de enfermedad, la sobrevida libre de proctectomía y las tasas de preservación de órgano.RESULTADOS:Se logró una respuesta clínica completa en 36 pacientes (58.1 %) frente a 59 pacientes (14.8 %) (p < 0,001) a favor del grupo de terapia neoadyuvante total. La sobrevida general a tres años fue similar entre los grupos (85.6 % quimiorradioterapia neoadyuvante estándar frente a 86.0 % terapia neoadyuvante total). La sobrevida libre de metástasis a distancia a los tres años fue del 67.4 % en el grupo de terapia neoadyuvante total y del 77.7 % en el grupo de quimiorradioterapia neoadyuvante estándar. La sobrevida sin proctectomía a los tres años fue del 44 % en el grupo de terapia neoadyuvante total frente al 6 % en el grupo de quimiorradioterapia neoadyuvante estándar. Veintidós pacientes (37.3 % con respuesta clínica completa) en el grupo de quimiorradioterapia neoadyuvante estándar optaron por la preservación de órgano, mientras que 31 pacientes (86.1 % respuesta clínica completa) del grupo de terapia neoadyuvante total eligieron la preservación de órgano.LIMITACIONES:Este estudio es un estudio retrospectivo con un seguimiento más corto de 3 años.CONCLUSIONES:La terapia neoadyuvante total para el cáncer de recto aumentó significativamente la respuesta clínica completa. Esto permitió a los pacientes tener una mayor preservación de órgano sin diferencias significativas en la sobrevida general o el control de la enfermedad. Consulte Video Resumen en http://links.lww.com/DCR/B934 . (Traducción-Dr. Jorge Silva Velazco ).

Intracorporeal and extracorporeal anastomosis for robotic-assisted and laparoscopic right colectomy: short-term outcomes of a multi-center prospective trial.

BACKGROUND: Studies to date show contrasting conclusions when comparing intracorporeal and extracorporeal anastomoses for minimally invasive right colectomy. Large multi-center prospective studies comparing perioperative outcomes between these two techniques are needed. The purpose of this study was to compare intracorporeal and extracorporeal anastomoses outcomes for robotic assisted and laparoscopic right colectomy. METHODS: Multi-center, prospective, observational study of patients with malignant or benign disease scheduled for laparoscopic or robotic-assisted right colectomy. Outcomes included conversion rate, gastrointestinal recovery, and complication rates. RESULTS: There were 280 patients: 156 in the robotic assisted and laparoscopic intracorporeal anastomosis (IA) group and 124 in the robotic assisted and laparoscopic extracorporeal anastomosis (EA) group. The EA group was older (mean age 67 vs. 65 years, p = 0.05) and had fewer white (81% vs. 90%, p = 0.05) and Hispanic (2% vs. 12%, p = 0.003) patients. The EA group had more patients with comorbidities (82% vs. 72%, p = 0.04) while there was no significant difference in individual comorbidities between groups. IA was associated with fewer conversions to open and hand-assisted laparoscopic approaches (p = 0.007), shorter extraction site incision length (4.9 vs. 6.2 cm; p ≤ 0.0001), and longer operative time (156.9 vs. 118.2 min). Postoperatively, patients with IA had shorter time to first flatus, (1.5 vs. 1.8 days; p ≤ 0.0001), time to first bowel movement (1.6 vs. 2.0 days; p = 0.0005), time to resume soft/regular diet (29.0 vs. 37.5 h; p = 0.0014), and shorter length of hospital stay (median, 3 vs. 4 days; p ≤ 0.0001). Postoperative complication rates were comparable between groups. CONCLUSION: In this prospective, multi-center study of minimally invasive right colectomy across 20 institutions, IA was associated with significant improvements in conversion rates, return of bowel function, and shorter hospital stay, as well as significantly longer operative times compared to EA. These data validate current efforts to increase training and adoption of the IA technique for minimally invasive right colectomy.

Transanal total mesorectal excision (taTME) for rectal cancer: beyond the learning curve.

BACKGROUND: Transanal total mesorectal excision (taTME) is a surgical approach for low rectal cancer with a learning curve estimated at 40-50 cases. The experience among taTME surgeons beyond their learning curve is limited. METHODS: A retrospective analysis of all taTME cases performed for rectal cancer at two tertiary care hospitals from 2014 to 2019 was conducted. Transanal surgeons had previously performed > 50 taTME cases. Demographic, perioperative, and short-term outcomes were analyzed. RESULTS: Among 54 taTME patients, 74.1% were male and 27.8% had a BMI ≥ 30. Tumors were stage I (8), II (13), III (29), and IV (4). Complex cases included 4 local recurrences, 4 prior liver resections, and 2 with prior prostate cancer. Thirty tumors were located ≤ 6 cm from the anal verge. On staging MRI, 12 had a positive predicted circumferential radial margin (+CRM), and 4 had internal anal sphincter involvement (+IAS). Forty-seven patients received neoadjuvant therapy. A 2-team approach was used in 51 patients with laparoscopic (83.3%) or robotic (16.7%) abdominal assistance with a 9.2% conversion rate. Low anterior resection with sphincter salvage was achieved in 87% with 8 patients requiring intersphincteric resection. Anastomoses were hand-sewn in 57.4% and all patients were diverted. Median LOS was 5 days with a 42.6% 30-day morbidity rate and 3 postoperative mortalities (ARDS, pulmonary embolism and pseudomembranous colitis). Complete and near complete TME grade was achieved in 94.4% with a 3.7% rate of +CRM. At a median follow-up of 28 months, local and distant recurrence rates were 3.9% and 17.6%, respectively, with no cancer-related mortality. CONCLUSION: Indications for taTME at experienced centers have expanded to include complex reoperative cases, local recurrences, metastatic cancer, and tumors with threatened CRM or IAS with evidence of post-treatment tumor regression. In the latter cases, taTME achieves good short-term outcomes and may facilitate R0 resection.

Learning Transanal Total Mesorectal Excision.

A dynamic evolution is occurring in transanal surgery. Transanal techniques began with intraluminal surgical removal of rectal masses and have progressed to transanal total mesorectal excision (taTME) for rectal cancer. TaTME was first performed in 2009 by Sylla, Rattner, Delgado, and Lacy. This article documents the training pathway followed by pioneers in the taTME technique as well as consensus reports outlining the process of learning the taTME technique. A literature search was performed for taTME training, learning, and technique. Key elements in learning the taTME technique include appropriate indications, cadaver training, and outcomes reporting such as participating in a taTME registry. Consensus reports also agree on the following facets associated with improved outcomes: (1) appropriate case selection of mid and low rectal cancers, (2) prerequisite completion of an accredited training program in laparoscopic colorectal surgery and prior experience in transanal endoscopic surgery, (3) a two-team taTME approach from above and below is ideal, and (4) higher rectal cancer volume surgical practice. The unifying international recommendation for surgeons interested in learning the taTME technique conveys the following message: taTME is an advanced and complex technique that requires dedicated training and experience in TME surgery.

Racial and Socioeconomic Treatment Disparities in Adolescents and Young Adults with Stage II-III Rectal Cancer.

INTRODUCTION: Stage II-III rectal cancer requires multidisciplinary cancer care, and adolescents and young adults (AYA, ages 15-39 years) often do not receive optimal cancer therapy. METHODS: Overall, 3295 AYAs with clinical stage II-III rectal cancer were identified in the National Cancer Database. Factors associated with the receipt of adjuvant and surgical therapies, as well as overall survival (OS), were examined. RESULTS: The majority of patients were non-Hispanic White (72.0 %), male (57.5 %), and without comorbidities (93.8 %). A greater proportion of Black and Hispanic patients did not receive radiation (24.5 and 27.1 %, respectively, vs. 16.5 % for non-Hispanic White patients), surgery (22.4 % and 21.6 vs. 12.3 %), or chemotherapy (21.5 % and 24.1 vs. 14.7 %) compared with non-Hispanic White patients (all p < 0.05). After controlling for competing factors, Black (odds ratio [OR] 0.7, 95 % confidence interval [CI] 0.5-0.9) and Hispanic patients (OR 0.6, 95 % CI 0.4-0.9) were less likely to receive neoadjuvant chemoradiation compared with non-Hispanic White patients. Females, the uninsured, and those treated at a community cancer center were also less likely to receive neoadjuvant therapy. Having government insurance (OR 0.22, 95 % CI 010-0.49) was a predictor for not receiving surgery. Although 5-year OS was lower (p < 0.05) in Black (59.8 %) and Hispanic patients (65.9 %) compared with non-Hispanic White patients (74.9 %), on multivariate analysis race did not impact mortality. Not having surgery (hazard ratio [HR] 7.1, 95 % CI 2.8-18.2) had the greatest influence on mortality, followed by poorly differentiated histology (HR 3.0, 95 % CI 1.3-6.5), nodal positivity (HR 2.6, 95 % CI 1.9-3.6), no chemotherapy (HR 1.9, 95 % CI 1.03-3.6), no insurance (HR 1.7, 95 % CI 1.1-2.7), and male sex (HR 1.5, 95 % CI 1.1-2.0). CONCLUSION: There are racial and socioeconomic disparities in the treatment of stage II-III rectal cancer in AYAs, many of which impact OS. Interventions that can address and mitigate these differences may lead to improvements in OS for some patients.

Transanal total mesorectal excision (taTME) for rectal cancer: a training pathway.

BACKGROUND: With increasing interest in natural orifice surgery, there has been a dramatic evolution of transanal and endoluminal surgical techniques. These techniques began with transanal endoluminal surgical removal of rectal masses and have progressed to transanal radical proctectomy for rectal cancer. The first transanal total mesorectal excision (taTME) was performed in 2009 by Sylla, Rattner, Delgado, and Lacy. The improved visibility and working space associated with the taTME technique is intriguing. This video manuscript outlines the training pathway followed by pioneers in the taTME technique, the process of implementation into clinical practice, and initial case report. METHODS: A double board-certified colorectal surgeon with expertise in rectal cancer, minimally invasive total mesorectal excision, transanal endoscopic surgery (TES), and intersphincteric dissection, underwent taTME training in male cadaver models. Institutional review board (IRB) approval for a phase I clinical trial was achieved. The entire operative team including surgeons, nurses, and operative staff underwent taTME cadaver training the day prior to the first clinical case. The case was proctored by an expert in taTME. RESULTS: A 66-year-old male with uT3N1M0 rectal cancer located in the posterior distal rectum, underwent taTME with laparoscopic abdominal assistance, hand sewn coloanal anastomosis, and diverting loop ileostomy. The majority of the TME was performed transanally with laparoscopic assistance for exposure, splenic flexure mobilization, and high ligation of the vascular pedicles. Operative time was 359 min. There were no intraoperative complications. Pathology revealed a ypT2N1 moderately differentiated invasive adenocarcinoma, grade I TME, 1 cm circumferential radial margin, and 2/13 positive lymph nodes. CONCLUSION: Implementation of taTME into practice can be achieved by surgeons with expertise in minimally invasive TME, TES, pre-clinical taTME training in cadavers, case observation, proctoring, and ongoing mentorship. IRB peer review process and participation in a clinical registry are additional measures that should be employed.

Outcomes of Simultaneous Versus Staged Resection for Stage IV Colorectal Cancer with Synchronous Liver Metastases.

INTRODUCTION: Management of stage IV colorectal cancer with synchronous liver metastases remains debated, as colorectal and liver resections can be performed simultaneously or staged apart. OBJECTIVE: This study aims to determine any demographic or outcome differences between simultaneous and staged resection. PARTICIPANTS: Retrospective review was performed on patients diagnosed with synchronous colorectal primary and liver metastases within Southern California Kaiser Permanente (KP) hospitals between 2010 and 2020. Patients with other metastases on diagnosis or those who did not receive both primary and liver resections were excluded. Demographic and outcome data were collected and analyzed. RESULTS: Of the 113 patients who met criteria, 72 (63.7%) received simultaneous and 41 (36.3%) received staged resection. Demographic data were comparable between simultaneous and staged resection, respectively, including median age of diagnosis, sex, and race. Both groups had similar median length of stay, percentage of major colorectal resection, and percentage of major liver resection. Both groups also had similar rates of radiation therapy, chemotherapy, and immunotherapy. There were no statistically significant difference in complications rates, median follow-up time, median overall survival, and median disease-free survival. CONCLUSIONS: Practice patterns within Southern California KP hospitals favor minor colorectal and liver resections. However, there were no significant differences in demographics, treatment rates, or outcomes between simultaneous and staged resection. While not statistically significant, our findings of a 11.9% higher major liver resection rate and 7.5-month longer median disease-free survival in the staged resection group may benefit from further study with higher power datasets.

A novel nomogram accurately quantifies the risk of mortality in elderly patients undergoing colorectal surgery.

OBJECTIVE: The ability to accurately predict postoperative mortality is expected to improve preoperative decisions for elderly patients considered for colorectal surgery. METHODS: Patients undergoing colorectal surgery were identified from the National Surgical Quality Improvement Program database (2005-2007) and stratified as elderly (>70 years) and nonelderly (<70 years). Univariate analysis of preoperative risk factors and 30-day mortality and morbidity were analyzed on 70% of the population. A nomogram for mortality was created and tested on the remaining 30%. RESULTS: Of 30,900 colorectal cases, 10,750 were elderly (>70 years). Mortality increased steadily with age (0.5% every 5 years) and at a faster rate (1.2% every 5 years) after 70 years, which defined "elderly" in this study. Elderly (mean age: 78.4 years) and nonelderly patients (52.8 years) had mortality of 7.6% versus 2.0% and a morbidity of 32.8% versus 25.7%, respectively. Elderly patients had greater preoperative comorbidities including chronic obstructive pulmonary disease (10.5% vs 3.8%), diabetes (18.7% vs 11.1%), and renal insufficiency (1.7% vs 1.3%). A multivariate model for 30-day mortality and nomogram were created. Increasing age was associated with mortality [age >70 years: odds ratio (OR) = 2.0 (95% confidence interval (CI): 1.7-2.4); >85 years: OR = 4.3 (95% CI: 3.3-5.5)]. The nomogram accurately predicted mortality, including very high-risk (>50% mortality) with a concordant index for this model of 0.89. CONCLUSIONS: Colorectal surgery in elderly patients is associated with significantly higher mortality. This novel nomogram that predicts postoperative mortality may facilitate preoperative treatment decisions.

Investigating Mortality Disparities Among Insured Patients With Colon Cancer Treated in an Integrated Health care System and Other Private Settings.

BACKGROUND: Lower socioeconomic status (SES) affects health care delivery and is associated with worse outcomes. Integrated healthcare systems (IHS) may help reduce barriers to health care and affect outcomes. Our aim was to compare outcomes of colon cancer cases diagnosed at the largest IHS in California, Kaiser Permanente Southern California (KPSC), to other insured patients (OI) to determine how SES influences mortality. METHODS: This retrospective cohort study included insured adults in southern California diagnosed with colon cancer between 2009 and 2014, using data from the California Cancer Registry, and followed through 2017. Main outcome was all-cause mortality. Person-year mortality rates were calculated for two groups, KPSC and OI. Multivariable hazard ratios were calculated for association between SES quintiles and mortality. RESULTS: Total of 15 923 patients were diagnosed with colon cancer, 4195 patients (26.3%) within KPSC and 11 728 patients (73.7%) in OI. The overall mortality rate per 1000 person-years (PY) was lower in KPSC [103.8/1000 PY (95% CI:98.5-109.3)] compared to OI [139.3/1000 PY (95% CI:135.2-143.4)]. Compared to the highest SES group, the lowest SES group did not experience higher mortality risk in the KPSC population, after adjusting for race/ethnicity and other factors (HR, 95% CI = 1.13, .93-1.38). However, in OI patients, lowest and lower-middle SES groups had higher mortality risk compared to the highest SES group (HR, 95% CI = 1.26, 1.13-1.40 and 1.28, 1.16-1.41, respectively). DISCUSSION: Lower SES was associated with higher mortality risk within the OI group; however, within KPSC no such association was observed. Care coordination in IHS settings mitigate SES-related mortality differences.

Metabolic Risk Factors Associated with Early-Onset Colorectal Adenocarcinoma: A Case-Control Study at Kaiser Permanente Southern California.

BACKGROUND: The incidence of early-onset colorectal cancer (eoCRC) diagnosed among individuals under age 50 has been rising. However, risk factors for eoCRC are unclear. We investigated whether metabolic abnormalities are risk factors for eoCRC adenocarcinoma. METHODS: Invasive colorectal adenocarcinoma cases diagnosed between ages 15 and 49 from 2008 to 2018 at Kaiser Permanente Southern California (KPSC) were identified. Those with a history of inflammatory bowel disease were excluded. Noncancer controls were selected 5:1 for each case matched by age, sex, and length of membership prior to index date. Data were collected from KSPC's electronic medical records. The exposures of interest included obesity, type II diabetes, hypertension, and dyslipidemia, assessed from ≥1 year prior to eoCRC diagnosis/index date. Conditional logistic regressions were used to evaluate the associations between these metabolic risk factors and risk of eoCRC adenocarcinoma, adjusting for race/ethnicity, smoking, family history, neighborhood socioeconomic status, and health care utilization. RESULTS: A total of 1,032 cases and 5,128 controls were included. Risk of colorectal adenocarcinoma was significantly associated with obesity [odds ratio (OR) = 1.41; 95% confidence interval (CI), 1.15-1.74], but not diabetes, hypertension or dyslipidemia. In analysis stratified by tumor location, obesity was significantly associated with risk of colon adenocarcinoma OR = 1.56 (1.17-2.07), but its association with rectal adenocarcinoma was less clear OR = 1.19 (0.85-1.68). No significant interaction was detected between obesity and age (≥40 vs. <40), and obesity and sex. CONCLUSIONS: Obesity was associated with risk for eoCRC adenocarcinoma. IMPACT: This finding could help inform early-onset colorectal adenocarcinoma screening and prevention recommendations.See related commentary by Hayes, p. 1775.

Transrectal Ultrasound MRI-Fusion Biopsy of Perirectal Mass.

This case report describes the novel use of ultrasound-guided MRI-fusion biopsy to sample an extraluminal perirectal mass. This is a 64-year-old man with a history of pT3N2b mucinous adenocarcinoma of the right colon with metastatic disease to the mesocolic lymph nodes. Two years after initial resection he was found on restaging CT to have a mass measuring ∼4.0 × 4.8 cm superior to the seminal vesicles. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed a moderately FDG avid soft tissue mass interposed between the prostate and the rectum. Multiparametric MRI revealed a 6.2 × 4.6 × 2.8 cm heterogeneous lobulated T2 hyperintense mass with enhancement just superior to the seminal vesicles. This mass was unable to be viewed using sigmoidoscopy. Using UroNAV technology, we were able to biopsy the mass in the clinic setting. Biopsy was confirmed as recurrent mucinous adenocarcinoma.

Watch-and-Wait Compared to Operation for Patients with Complete Response to Neoadjuvant Therapy for Rectal Cancer.

BACKGROUND: Trimodality therapy with neoadjuvant chemoradiation (nCRT), surgery, and adjuvant chemotherapy is the standard treatment for locally advanced rectal cancer. There is evidence that surgery can be deferred in patients with complete response (CR) to nCRT, a strategy termed "watch-and-wait" (WW). We compare WW to surgery in patients with CR to nCRT. STUDY DESIGN: We reviewed records of patients treated with nCRT for nonmetastatic rectal cancer at our institution. Complete endoscopic response (CER) was defined as negative digital rectal exam and negative endoscopy at the end of neoadjuvant therapy (NAT). Clinical complete response (cCR) was defined as CER with negative rectal MRI. Patients with CER refusing surgery were offered WW, which included strict surveillance with digital rectal exam and endoscopy. RESULTS: From January 2015 through February 2019, 465 patients completed nCRT; 406 patients had response assessment, of which 95 (23%) had CER. Of these patients, 53 patients underwent WW and 42 patients had surgery. Median follow-up was 35 months. In the WW group, 3-year freedom from local regrowth was 85%. In the surgical and WW groups, 3-year overall survival, rectal cancer-specific survival, and freedom from nonregrowth recurrence were 100% vs 88% (p = 0.03), 100% vs 95% (p = 0.16), and 92% vs 85% (p = 0.36), respectively. Of the 6 WW patients with local regrowth, 5 (83%) eventually developed distant recurrence. CONCLUSIONS: WW in lieu of surgery appears to be a safe and feasible treatment approach for patients achieving CR to nCRT. Careful evaluation to confirm cCR after nCRT is valuable in selecting patients for WW.

Transanal Total Mesorectal Excision (taTME) for Rectal Cancer: A Case Series Report of a Natural Orifice Surgical Technique.

In the treatment of colorectal cancer, total mesorectal excision (TME) has risen as the gold standard in the surgical treatment of this disease in order to obtain negative distal and circumferential radial margins. Since introduction in 2010, transanal TME has aimed to decrease the rate of positive margins and improve the quality of the dissection while decreasing the complications associated with a transabdominal low pelvic dissection. We retrospectively reviewed 25 cases of transanal TME completed between December 2014 and August 2017. Most of the patients in our case series were male (60%) with an average age of 57.1 years, BMI of 28.4 kg/m², and with an American Society of Anesthesiologists score of II. The average tumor was midrectal (about 5.9 cm from the anal verge), clinically T3-T4 (92%), and had undergone neoadjuvant therapy (96%). The average operation was about six hours and 44 minutes with ileostomy placed most of the time (92%). In all the cases where the TME quality was graded, the specimens were reported to have been complete (grade I). There were no positive distal, radial, or proximal margins. The average hospital stay was about 5.9 days. The rate of minor complications was about 48 per cent and major complications occurred about 16 per cent of the time.

Obesity does not adversely affect outcomes after laparoscopic splenectomy.

BACKGROUND: Obesity is still considered a relative contraindication to laparoscopic splenectomy (LS). METHODS: All patients undergoing LS at our institution were classified as obese or nonobese (group A, body mass index [BMI] >30; group B, BMI <30). Primary end points included conversion rate, operative complications, length of stay, operative time, and estimated blood loss (EBL). RESULTS: Three hundred seventy patients who underwent LS were included. Baseline characteristics were similar in groups A (n = 127; mean BMI, 36.2 ± 6.9 kg/m²) and B (n = 243; mean BMI, 24.6 ± 2.9 kg/m²). Conversion rates and overall morbidity were similar in both groups (9% vs 11% for conversion to open procedures, P = .621; 16% vs 16% for morbidity rates, P = .940). Length of hospital stay and EBL were also comparable (P = .643 and P = .544, respectively). Mean operative time was significantly increased in the obese group on multivariate analysis (170 vs 151 minutes, P = .021). CONCLUSIONS: Obesity does not adversely affect outcomes after LS. The laparoscopic approach is the optimal technique for splenectomy regardless of the patient's weight.

Risk factors for urinary tract infections in colorectal compared with vascular surgery: a need to review current present-on-admission policy?

BACKGROUND: To reduce cost, the Centers for Medicare and Medicaid Services adopted a nonpayment policy for "reasonably preventable events" including hospital acquired urinary tract infection (UTI). Type of operation a patient undergoes could be an inevitable nonmodifiable risk factor in the development of UTI. STUDY DESIGN: Using Participant User File for National Surgical Quality Improvement Program (NSQIP) data from 2005 to 2007, vascular and colorectal cases were identified using CPT codes and analyzed for UTI incidence and risk factors within each group. RESULTS: We identified 30,900 colorectal cases and 39,246 vascular cases with 1,289 (4.2%) colorectal and 952 (2.4%) vascular UTI cases. A multivariate analysis of the dataset revealed colorectal procedures as an independent risk factor for the development of UTI. Subset analysis revealed this significant relationship only for patients with low (<0.30) and intermediate (0.30 to 0.70) morbidity probability. Comparing only open intra-abdominal colorectal and vascular procedures revealed UTI rates of 3.9% versus 4.7%. Multivariate analysis revealed no significant difference in UTI rates in intraabdominal cases (all p values < 0.05). Subset analysis for the open cases revealed that colorectal procedures continued to be associated with UTI in low morbidity probability cases only. CONCLUSIONS: Current policy to reward higher quality fails to differentiate between UTI that may be preventable versus one likely due to nonmodifiable risk factors. Colorectal surgery is more likely to result in higher rates of UTI in comparison with vascular surgery, which may be related to type and complexity of a procedure. Further research needs to be done to change this policy to take into account this nonmodifiable risk factor.

Advanced laparoscopic techniques significantly improve function of peritoneal dialysis catheters.

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) catheters provide a preferred alternative to hemodialysis in a growing population with chronic kidney disease. However, CAPD catheters traditionally have been associated with a high rate of nonfunction with both open and laparoscopic procedures. New advanced laparoscopic techniques using rectus sheath tunneling and omentopexy have been reported to improve catheter function. STUDY DESIGN: This study retrospectively reports the Cleveland Clinic experience during the transition from basic to advanced laparoscopic techniques from June 2002 to July 2008. A total of 197 patients were identified: 68 who underwent insertion with basic techniques and 129 who received catheters with advanced techniques. Primary nonfunction, procedural complications, and overall nonfunction rate were analyzed using the most recent follow-up to June 2008. RESULTS: Primary nonfunction occurred in 25 of 68 (36.7%) patients in the basic group; this occurred in only 6 of 129 patients (4.6%) in the advanced group (p < 0.0001). The overall rate of complications including nonfunction from primary and secondary sources, peritoneal leak, peritonitis, port-site hernia, and bleeding occurred in 31 of 68 (45.6%) patients in the basic group and 21 of 129 (16.28%) patients in the advanced group (p < 0.0001). CONCLUSIONS: These data clearly show a significant improvement in CAPD catheter function using omentopexy and rectus sheath tunneling. These advanced laparoscopic techniques should become the preferred method of CAPD catheter insertion.

A multi-institutional phase II trial of preoperative full-dose gemcitabine and concurrent radiation for patients with potentially resectable pancreatic carcinoma.

BACKGROUND: We report the results of a multi-institutional phase II trial that used preoperative full-dose gemcitabine and radiotherapy for patients with potentially resectable pancreatic carcinoma. METHODS: Patients were treated before surgery with three cycles of full-dose gemcitabine (1000 mg/m2 intravenously), with radiation during the second cycle (36 Gy in daily 2.4-Gy fractions). Patients underwent surgery 4 to 6 weeks after the last gemcitabine infusion. RESULTS: There were 10 men and 10 women, with a median age of 58 years (range, 50-80 years). Nineteen patients (95%) completed therapy without interruption, and one experienced grade 3 gastrointestinal toxicity. The mean weight loss after therapy was 4.0%. Of 20 patients taken to surgery, 17 (85%) underwent resections (16 pancreaticoduodenectomies and 1 distal pancreatectomy). The complication rate was 24%, with an average length of stay of 13.5 days. There were no operative deaths. Pathologic analysis revealed clear margins in 16 (94%) of 17 and uninvolved lymph nodes in 11 (65%) of 17 specimens. One specimen contained no residual tumor, and three specimens revealed only microscopic foci of residual disease. With a median follow-up of 18 months, 7 (41%) of the 17 patients with resected disease are alive with no recurrence, 3 (18%) are alive with distant metastases, and 7 (41%) have died. CONCLUSIONS: Preoperative gemcitabine/radiotherapy is well tolerated and safe when delivered in a multi-institutional setting. This protocol had a high rate of subsequent resection, with acceptable morbidity. The high rate of negative margins and uninvolved nodes suggests a significant tumor response. Preliminary survival data are encouraging. This regimen should be considered in future neoadjuvant trials for pancreatic cancer.