Management, Functional Outcomes, and Quality of Life After Development of Pelvic Sepsis in Patients Undergoing Re-Do Ileal Pouch Anal Anastomosis.

BACKGROUND: The data on management and outcomes of pelvic sepsis after re-do IPAA are scarce. OBJECTIVE: The aim of this study is to report our management algorithm of pelvic sepsis in the setting of re-do IPAA and compare functional outcomes and quality of life after successful management of pelvic sepsis with a no sepsis control group. DESIGN: This is a retrospective cohort study. SETTINGS: This investigation is based on a single academic practice group experience on re-do IPAA. PATIENTS: Patients who underwent re-do IPAA for ileal pouch failure between September 2016 and September 2020 were included in the study. MAIN OUTCOME MEASURES: Management of pelvic sepsis was reported. Functional outcomes, restrictions, and quality-of-life scores were compared between the sepsis and no sepsis groups. RESULTS: One-hundred ten patients were included in our study, of whom 25 (22.7%) developed pelvic sepsis. Twenty-three patients presented with pelvic sepsis before ileostomy closure, and 2 patients presented with pelvic sepsis after ileostomy closure. There were 6 pouch failures in the study period due to pelvic sepsis. Our management was successful in 79% of the patients with median follow-up of 26 months. Treatments included interventional radiology abscess drainage (n = 7), IV antibiotics alone (n = 5), interventional radiology drainage and mushroom catheter placement (n = 1), mushroom catheter placement (n = 1), and endoluminal vacuum-assisted closure (n = 1). Average number of bowel movements, urgency, incontinence, pad use, and seepage were comparable between the pelvic sepsis and no pelvic sepsis groups ( p > 0.05). Lifestyle alterations, Cleveland Global Quality of Life scores, and happiness with the results of the surgery were similar ( p > 0.05). LIMITATIONS: This study is limited by its low study power and limited follow-up time. CONCLUSIONS: Pelvic sepsis is common after re-do IPAA, and management varies according to the location and size of the abscess/sinus. If detected early, our management strategy was associated with high pouch salvage rates. See Video Abstract at http://links.lww.com/DCR/B823 . MANEJO, RESULTADOS FUNCIONALES Y CALIDAD DE VIDA DESPUS DEL DESARROLLO DE SEPSIS PLVICA EN PACIENTES SOMETIDAS A RECONFECCIN DE ANASTOMOSIS ANAL CON BOLSA ILEAL: ANTECEDENTES:Los datos sobre el tratamiento y los resultados de la sepsis pélvica después de reconfección de anastomosis anal, de la bolsa ileal son escasos.OBJETIVO:El objetivo de este estudio es informar nuestro algoritmo de manejo de la sepsis pélvica en el contexto de reconfección de anastomosis anal de la bolsa ileal y comparar los resultados funcionales y la calidad de vida después del manejo exitoso de la sepsis pélvica con un grupo de control sin sepsis.DISEÑO:Este es un estudio de cohorte retrospectivo.AJUSTES:Esta investigación se basa en una experiencia de un solo grupo de práctica académica sobre reconfección de IPAA.PACIENTES:Se incluyeron en el estudio pacientes que se sometieron a una nueva anastomosis anal, del reservorio ileal por falla del reservorio ileal entre el 09/2016 y el 09/2020.PRINCIPALES MEDIDAS DE RESULTADO:Se informó el manejo de la sepsis pélvica. Los resultados funcionales, las restricciones y las puntuaciones de calidad de vida, se compararon entre los grupos con sepsis y sin sepsis.RESULTADOS:Se incluyeron 110 pacientes en nuestro estudio, de los cuales 25 (22,7) desarrollaron sepsis pélvica. Veintitrés pacientes presentaron sepsis pélvica antes del cierre de la ileostomía y 2 pacientes presentaron sepsis pélvica después del cierre de la ileostomía. Hubo 6 fallas de la bolsa en el período de estudio debido a sepsis pélvica. Nuestro manejo fue exitoso en el 79% de los pacientes con una mediana de seguimiento de 26 meses. Los tratamientos incluyeron drenaje de abscesos IR (n = 7), antibióticos intravenosos solos (n = 5), drenaje IR y colocación de catéter en forma de hongo (n = 1), colocación de catéter en forma de hongo (n = 1) y cierre endoluminal asistido por vacío (n = 1). El número promedio de evacuaciones intestinales, urgencia, incontinencia, uso de almohadillas y filtraciones fueron comparables entre los grupos con sepsis pélvica y sin sepsis pélvica ( p > 0,05). Las alteraciones del estilo de vida, las puntuaciones de la Calidad de vida global de Cleveland y la felicidad con los resultados de la cirugía fueron similares ( p > 0,05).LIMITACIONES:Este estudio está limitado por su bajo poder de estudio y su tiempo de seguimiento limitado.CONCLUSIONES:La sepsis pélvica es común después de la reconfección de anastomosis anal de la bolsa ileal y el manejo varía según la ubicación y el tamaño del absceso / seno. Si se detecta temprano, nuestra estrategia de manejo se asoció con altas tasas de recuperación de la bolsa. Consulte Video Resumen en http://links.lww.com/DCR/B823 . (Traducción-Dr. Mauricio Santamaria ).

Operative, long-term and quality of life outcomes after salvage of failed re-do ileal pouch anal anastomosis.

AIM: Approximately 20%-40% of the patients with re-do ileal pouch anal anastomosis (IPAA) experience pouch failure. Salvage surgery can be attempted in this patient group with severe aversion to permanent ileostomy. The literature regarding secondary IPAA revision after re-do IPAA failure is scarce. METHODS: All patients who underwent a secondary IPAA revision after re-do IPAA failure between September 2016 and July 2021 in a single centre were included. Short- and long-term outcomes and quality of life in this patient group are reported. RESULTS: Ten patients who had secondary IPAA revision for re-do IPAA failure were included. All patients had ulcerative colitis. Nine of these patients had pelvic sepsis and one patient had a mechanical issue. Mucosectomy and handsewn anastomosis was performed in nine patients. The existing pouch was salvaged in six patients and four patients had pouch excision and re-creation. Two patients had postoperative pelvic sepsis. Pouch retention rate was 78% in a median of 28 months. None of the patients had short-gut syndrome. The procedure was associated with good quality of life (median Cleveland Global Quality of Life Index 0.8). All patients would undergo the same surgery if needed. CONCLUSION: Secondary IPAA revision after a failed re-do IPAA can be an option in patients with severe aversion to permanent ileostomy if re-do IPAA fails and it is associated with good outcomes. This patient group should be carefully evaluated and referred to specialized centres if required.

Handsewn Versus Stapled IPAA in Redo Setting: Indications, Patient Characteristics, Operative, Functional, and Quality-of-Life Outcomes.

BACKGROUND: The impact of the type of anastomosis on the outcomes of redo IPAA is unknown. OBJECTIVE: The aim of this study is to assess the indications, perioperative outcomes, and functional outcomes in patients undergoing stapled vs handsewn redo IPAA. DESIGN: This is a retrospective cohort study. SETTINGS: This investigation is based on a single academic practice group experience with redo IPAA. PATIENTS: Patients who underwent redo IPAA for ileal pouch failure between September 2016 and May 2020 were included in the study. MAIN OUTCOME MEASURES: Indications, perioperative outcomes, functional outcomes, restrictions, and quality-of-life scores were compared between stapled and handsewn groups. RESULTS: A total of 105 patients underwent redo IPAA for ileal pouch failure of whom 76 (72%) had handsewn and 29 (28%) had stapled reanastomosis. The interval between the index and redo IPAA was shorter in stapled redo IPAA (median (interquartile range), Stapled: 3 years (1-4) vs handsewn: 7 years (3-17), p < 0.001). Handsewn anastomosis was more commonly used after pelvic sepsis (handsewn: n = 57 (76%) vs stapled: n = 13 (45%), p = 0.002). Overall postoperative morbidity was similar between the 2 groups (handsewn: n = 38 (50%) vs stapled: n = 16 (55%), p = 0.635). The number of bowel movements, pad use, daily restrictions, and Cleveland Global Quality of Life scores were similar between stapled and handsewn groups. Although daytime seepage was more common after handsewn anastomosis (handsewn, n = 20 (44%) vs stapled, n = 3 (14%), p = 0.013), nighttime seepage was similar in both groups. Pouch survival rates were comparable: 88% vs 92% (p > 0.05). LIMITATIONS: This study is limited by its low study power and limited follow-up time. CONCLUSIONS: Patients who had pelvic sepsis after their index IPAA required handsewn anastomosis at higher rates than other redo cases. Although handsewn anastomosis is a more complex procedure, it is associated with morbidity, functional outcomes, and quality-of-life scores similar to stapled anastomosis for redo IPAA. See Video Abstract at http://links.lww.com/DCR/B580. RECONSTRUCCIN DE ANASTOMOSIS ILEONAL CON RESERVORIO ILEAL CON SUTURA MANUAL VERSUS ANASTOMOSIS CON ENGRAPADO INDICACIONES, CARACTERSTICAS DEL PACIENTE, RESULTADOS OPERATORIOS, FUNCIONALES Y DE CALIDAD DE VIDA: ANTECEDENTES:Se desconoce el impacto en los resultados del tipo de anastomosis se rehace una anastomosis ileonal con reservorio ileal (IPAA).OBJETIVO:El propósito de este estudio es evaluar las indicaciones, resultados perioperatorios y funcionales en pacientes sometidos a una reconstrucción IPAA con engrapado vs sutura manual.DISEÑO:Este es un estudio de cohorte retrospectivo.ENTORNO CLINICO:Esta investigación se basa en la experiencia de un solo grupo de práctica académica sobre reconstrucción IPAA.PACIENTES:Se incluyeron en el estudio pacientes que fueron sometidos a una reconstrucción de IPAA por falla del reservorio ileal entre septiembre del 2016 hasta mayo del 2020.PRINCIPALES MEDIDAS DE VALORACION:se compararon indicaciones, resultados perioperatorios, funcionales, restricciones y puntuaciones de calidad de vida entre los grupos de engrapado y sutura manual.RESULTADOS:Un total de 105 pacientes fueron sometidos a una reconstrucción de IPAA por falla del reservorio ileal, de los cuales 76 (72%) fueron reanastomosis con sutura manual y 29 (28%) con engrapado. El intervalo entre la cirugía inicial y la reintervención de IPAA fue más corto en la reconstrucción de IPAA con engrapado [mediana (IQR), engrapado: 3 años (1-4) vs con sutura manual: 7 años (3-17), p <0,001]. La anastomosis con sutura manual se realizo con mayor frecuencia después de sepsis pélvica [sutura manual: n = 57 (76%) vs engrapado: n = 13 (45%), p = 0,002]. La morbilidad postoperatoria total fue similar entre los dos grupos [sutura manual: n = 38 (50%) vs engrapado: n = 16 (55%), p = 0,635]. El número de evacuaciones intestinales, el uso de paños protectores, restricciones diarias y puntuaciones en CGQL fueron similares entre los grupos de engrapado y sutura manual. Si bien el manchado por la mañana fue más común después de la anastomosis con sutura manual [sutura manual, n = 20 (44%) vs engrapado, n = 3 (14%), p = 0.013], el manchado por la noche fue similar en ambos grupos. Las tasas de sobrevida con reservorio fueron comparables; 88% vs 92% respectivamente (p> 0,05).LIMITACIONES:Este estudio está limitado por su bajo poder de estudio y su tiempo de seguimiento limitado.CONCLUSIONES:Los pacientes que tuvieron sepsis pélvica después de su primer IPAA, requirieron anastomosis con sutura manual en un porcentaje más alto que otros procedimientos de reintervención. Si bien es cierto, la anastomosis con sutura manual es un procedimiento mucho más complejo; este se asoció a una morbilidad, resultados funcionales y puntuaciones de calidad de vida similares en comparación a la anastomosis con engrapado cuando se rehace la IPAA. Consulte Video Resumen en http://links.lww.com/DCR/B580. (Traducción- Dr. Francisco M. Abarca-Rendon).

Achieving Opioid-Free Major Colorectal Surgery: Is It Possible?

INTRODUCTION: Opioid analgesia remains the mainstay of postoperative pain management strategies despite being associated with many adverse effects. A specific opioid-free protocol was designed to limit opioid usage. OBJECTIVE: The aim of the study was to audit the opioid-free rate within this protocol and to identify factors that might contribute to opioid-free surgery. METHODS: A retrospective study of all elective patients receiving abdominal colorectal surgery at the Center for Colon and Rectal Surgery at AdventHealth over 6 months was performed. Data on demographics, indications, perioperative management, outcomes, and inpatient and outpatient analgesic requirements were collected with subsequent analysis. RESULTS: A total of 303 consecutive patient records were analyzed. Approximately two-thirds (67.7%) of patients did not receive narcotics once they left the postanesthesia care unit as an inpatient. One-third of patients (32.0%) did not receive narcotic analgesia within 30 days of surgery as an outpatient. Patients in the opioid-free cohort were significantly older and had a malignant indication, less perioperative morbidity, and a shorter length of stay. CONCLUSIONS: Our study demonstrates that opioid-free analgesia is indeed possible in major colorectal surgery. Study limitations include its retrospective nature and that it is from a single institution. Despite these limitations, this study provides proof of concept that opioid-free colorectal surgery is possible within a specific protocol.

Pouch abandonment is extremely rare even in the reoperative setting: A high-volume referral center experience.

BACKGROUND: Ileal pouch anal anastomosis is the preferred method for restoration of intestinal continuity after proctocolectomy. Successful ileal pouch anal anastomosis requires adequate reach of the ileal mesentery to the pelvis. Reach issues are a common cause for intraoperative pouch abandonment; however, data regarding contemporary abandonment rates are rare and nonexistent in the revisional setting. METHODS: A retrospective review was conducted of consecutive ileal pouch anal anastomosis surgery at a single referral center. Both initial or "primary" pouches and revisional pouch surgery were included. RESULTS: In total, 447 attempts at pouch anal anastomosis were made, with an 1.6% overall rate of intraoperative abandonment. Pouch abandonment was attributed to inadequate mesenteric reach during 3 surgeries, desmoid tumors in 2 surgeries, and insufficient remaining small bowel in 2 surgeries. Twelve patients required lengthening maneuvers including 6 S pouches (1%) and 6 H pouches (1%). One half (49%) of operations were revisional ileal pouch anal anastomosis surgery. Overall, reach issues led to intraoperative abandonment in only 0.4% of attempted primary pouches and 1.0% of revisional surgeries. A preoperative diagnosis of familial adenomatous polyposis was associated with pouch abandonment (P < .001). CONCLUSION: Extremely low pouch abandonment rates as a result of mesenteric reach can be achieved even in the revisional setting at a high-volume center with institutional expertise. In the revisional setting, intra-abdominal desmoids or the potential for short gut affects pouch abandonment rates as much as reach issues.

Stapled End-To-Side Ileocolic Anastomosis in Crohn's Disease: Old Dog, Reliable Tricks? A Retrospective Two-Center Cohort Study.

Objective: Analyze our long-term experience with a less-popularized but stalwart approach, the stapled end-to-side ileocolic anastomosis. Background: The choice of technical approach to ileocolic anastomosis after ileocecal resection for Crohn's disease affects surgical outcomes and recurrence. Yet, despite heterogeneous data from different anastomotic configurations, there remains no clear guidance as to the optimal technique. Methods: In a retrospective cohort design, patients undergoing ileocolic anastomosis in the setting of Crohn's disease between 2016 and 2021 at two institutions were identified. Patient characteristics and surgical outcomes in terms of recurrence (surgical, clinical, and endoscopic) were studied. Results: In total, 211 patients were included. Before surgery, 80% were exposed to at least 1 cycle of systemic steroids and 71% had at least 1 biologic agent; 60% exhibited penetrating disease and 38% developed an intra-abdominal abscess. After surgery, one anastomosis leaked (0.5%). Over 2.4 years of follow-up (IQR = 1.3-3.9), surgical recurrence was 0.9%. Two-year overall recurrence-free and endoscopic recurrence-free survivals were 74% and 85% (95% CI = 68-81 and 80-91), respectively. The adjusted hazard ratio of endoscopic recurrence was 3.0 (95% CI = 1.4-6.2) for males and 5.2 (1.2-22) for patients who received systemic steroids before the surgery. Conclusion: The stapled end-to-side anastomosis is an efficient, reliable, and reproducible approach to maintain bowel continuity after ileocecal resection with durable outcomes. Our outcomes demonstrate low rates of disease recurrence and stand favorably in comparison to other more technically complex or protracted anastomotic approaches. This anastomosis is an ideal reconstructive approach after ileocecal resection for Crohn's disease.

Preoperative cross-sectional imaging findings in patients with surgically complex ileocolic Crohn's disease.

PURPOSE: The aim of this study was to evaluate the diagnostic performance of preoperative cross-sectional imaging findings using the SAR-AGA definitions in Crohn's disease (CD) patients who underwent ileocolic resection (ICR) with and without surgically complex ileocolic CD (CIC-CD). METHODS: 69 CD patients [38 men; mean (± SD) age: 40.6 (16.2) years] who underwent ICR were retrospectively classified by surgical complexity by a colorectal surgeon using operative findings. CIC-CD was defined as ileal CD, not confined to the distal ileum. Two radiologists retrospectively evaluated the preoperative imaging for the presence and type of penetrating disease, stricture, or probable stricture using the SAR-AGA consensus definitions. The diagnostic performance of preoperative imaging findings was compared for patients with and without CIC-CD. Estimated blood loss (EBL), operative time (OT), conversion to open surgery, diversion, and length of hospital stay (LOS) were compared. RESULTS: 60.9% had CIC-CD and 79.7% underwent primary ICR. Penetrating disease was more common in patients with than without CIC-CD (76.2% vs. 40.7%, p = 0.0048) and similar among primary versus redo ICR (p = 0.12). Patients with CIC-CD had more complex fistulas (59.5% vs. 11.1%; p < 0.0001) and fewer simple fistulas (2.4% vs. 18.5%; p = 0.03) than those without. Mesenteric findings (abscess, inflammatory mass) were more frequent in patients with (35.7%) than without (0%) (p = 0.0002) CIC-CD. Stricture and probable stricture were similar (p = 0.59). CIC-CD patients had greater EBL (178 cc vs. 57 cc, p = 0.006), conversion rates (30% vs. 0%, p = 0.0026), and diversion (80% vs. 52%, p = 0.04). CONCLUSION: Complex fistula, mesenteric abscess, or inflammatory mass defined by the SAR-AGA guidelines suggests CIC-CD. ICR for CIC-CD had greater EBL, conversion to open surgery, and diversion.

Indications, functional and quality of life outcomes of new pouch creation during re-do ileal pouch anal anastomosis: A comparative study with existing pouch salvage.

BACKGROUND: Salvage of the existing ileal pouch is favored during re-do ileal pouch anal anastomosis if the pouch is not damaged after pelvic dissection and there are no other mechanical reasons that may necessitate construction of a new pouch. Excision of the existing pouch may be associated with some concerns for short-bowel syndrome and poor functional outcomes. This study aimed to report indications and compare functional and quality of life outcomes of new pouch creation versus salvage of the existing pouch during re-do ileal pouch anal anastomosis. METHODS: Patients who underwent re-do ileal pouch anal anastomosis between September 2016 and June 2020 were included. The reasons for pouch excision and new pouch creation were reported. Perioperative, functional outcomes and quality of life were compared between patients who had creation of a new pouch versus salvage of existing pouch. RESULTS: A total of 105 patients with re-do ileal pouch anal anastomosis (new pouch, n = 63) were included. Most common indications for a new pouch creation were chronic pelvic infection that compromised the integrity and viability of the existing pouch (n = 32) and small pouch (n = 21). No patient developed short-bowel syndrome. The number of bowel movements, daily restrictions and Cleveland Global Quality of Life score scores were similar between 2 groups. Day-time seepage, day-time and night-time pad usage were more common after new pouch creation. Two-year pouch survival rates were comparable (new pouch: 92% versus existing pouch: 85%, P = .31). CONCLUSION: New pouch creation can be safely performed at the time of re-do ileal pouch anal anastomosis. It provides acceptable functional and quality of life outcomes if existing pouch salvage is not feasible.

Ileal Pouch Excision can Be Performed With Similar Outcomes in Obese Patients Compared to Nonobese Counterparts: An Assessment From American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Failed pouches may tend to be managed with only a loop ileostomy in obese patients due to some safety concerns. The effect of obesity on ileal pouch excision outcomes is poorly studied. In our study, we aimed to assess the short-term outcomes after ileal pouch excision in obese patients compared to their nonobese counterparts. METHODS: The patients who underwent pouch excision between 2005 and 2017 were included using ACS-NSQIP participant user files. The operative outcomes were compared between obese (BMI ≥30 kg/m2) and nonobese (BMI<30 kg/m2) groups. RESULTS: There were 507 pouch excision patients included of which eighty (15.7%) of them were obese. Physical status of the obese patients tended to be worse (ASA>3, 56.3 vs 42.9%, P = .027). There were more patients who had diabetes mellitus (DM) and hypertension (HT) in the obese group (26.3% vs. 11.2%, P = .015; 11.3 vs. 4.4%, P < .001, respectively). Operative time was similar between 2 groups (mean ± SD, 275 ± 111 vs. 252±111 minutes, P = .084). Deep incisional SSI was more commonly observed in the obese group (7.5 vs 2.8%, P = .038). In multivariate analysis, only deep incisional SSI was found to be independently associated with obesity (OR: 2.79, 95% CI: 1.02-7.67). Obese patients were readmitted more frequently than nonobese counterparts (28.3 vs 16%, P = .035). The length of hospital stay was comparable [median (IQR), 7 (4-13.5) vs. 7 (5-11) days, P = .942]. CONCLUSION: Ileal pouch excision can be performed in obese patients with largely similar outcomes compared to their nonobese counterparts although obesity is associated with a higher rate of deep space infection.

Examining the relationship between lymph node harvest and survival in patients undergoing colectomy for colon adenocarcinoma.

BACKGROUND: Current standards for lymph node harvest in colorectal cancer surgery may be inadequate. Higher lymph node yield may improve survival, but the number of lymph nodes needed to optimize survival is unknown. The objective of this study was to examine the relationship between lymph node yield and overall survival in patients undergoing colectomy for nonmetastatic colon adenocarcinoma. METHODS: The 2010 to 2014 National Cancer Database was queried for patients undergoing colectomy for nonmetastatic colon adenocarcinoma. Adjusted restricted cubic splines were used to model the nonlinear relationship between lymph node harvest and overall survival. Cox proportional hazard determined independent predictors of overall survival. RESULTS: A total of 261,423 patients were included. Restricted cubic splines demonstrated that the adjusted improvements in overall survival stabilized after 24 nodes. Patients were divided into: <12, 12 to 23, and ≥24 nodes. On survival analysis, patients with ≥24 nodes had better survival across all N stages compared to other groups (P < .001). Lymph node harvest ≥24 nodes was independently associated with improved overall survival compared to 12 to 23 nodes (hazard ratio 0.82; 95% confidence interval, 0.80-0.85). CONCLUSION: Lymph node harvest ≥24 nodes is associated with improved survival in colorectal cancer patients. These data may provide indirect evidence for a more extensive lymphadenectomy for colon cancer.

Impact of residual nodal involvement after complete tumor response in patients undergoing neoadjuvant (chemo)radiotherapy for rectal cancer.

BACKGROUND: The management of patients with a complete clinical response after neoadjuvant therapy for rectal adenocarcinoma is controversial. Those who advocate for resection point out the inaccuracy of N-staging with current imaging modalities. The objective of this study is to determine the impact of residual nodal involvement after complete tumor regression after neoadjuvant (chemo)radiotherapy. METHODS: The 2004 to 2014 National Cancer Database was queried for patients undergoing proctectomy for nonmetastatic rectal adenocarcinoma who had received neoadjuvant (chemo)radiotherapy and with ypT0 on final pathology. Patients were grouped based on pathologic nodal stage: ypT0N- and ypT0N+. The main outcome was 5-year overall survival. RESULTS: There were 5,156 patients with ypT0N- and 527 with ypT0N+. Mean lymph node harvest was similar (ypT0N- 12.2 nodes [standard deviation 9.1] vs ypT0N+ 11.6 nodes [standard deviation 10.3]; P = .086). Patients with ypT0N+ were more likely to have had clinically involved nodes (P < .001) and earlier clinical T-stage (P = .002). Overall survival at 5 years was less for patients with ypT0N+ (80% vs 86%, log-rank P = .014). ypT0N+ was independently associated with worse overall survival (hazard ratio 1.74, 95% confidence interval 1.33-2.28). CONCLUSION: Residual nodal involvement despite complete tumor regression was associated with worse 5-year overall survival compared to complete pathologic response. Additional therapy should be considered in the presence of complete clinical tumor regression after neoadjuvant (chemo)radiotherapy.

Scope or scalpel? A matched study of the treatment of large colorectal polyps.

BACKGROUND: Large colorectal polyps can be treated either endoscopically or by formal resection. The aim of this study was to clarify the relative advantages and disadvantages of surgical resection and colonoscopic snaring as means of treating large colorectal polyps. METHODS: This is a matched cohort study, comparing cases of surgical resection of benign colorectal polyps with endoscopic resection. Cases drawn from pathology and endoscopy databases were matched for the size and site of polyps, and the groups were compared for the end points of complications, length of hospital stay and completeness of the removal of the polyp. RESULTS: There were 78 patients in each group, with mean ages of 65.6 years (colonoscopy) and 66.8 years (surgery). A total of 39 of the surgery group and 47 of the colonoscopy group were men. Mean polyp size was 34.1 mm (colonoscopy) and 32.1 mm (surgery). There was an exact match for polyp location. Complications occurred in eight colonoscopy patients (10.3%) and 42 surgery patients (56.0%) (P < 0.001, chi-square). Length of hospital stay was 0 days for colonoscopy patients and 7.3 ± 4.7 days for surgery (P < 0.001). The surgery group was separated into laparoscopic (n = 35) and open (n = 43) surgery. There was no difference in complication rates (42.4 versus 53.5%, respectively) but laparoscopic had shorter length of stay (5.8 days ± 4.9 SD versus 8.4 days ± 4.3 SD). Recurrence of surgically resected polyps was zero; at last follow-up 13% of snared polyps persisted. CONCLUSION: Although resection is a more certain and absolute way of treating benign polyps, endoscopic polypectomy is preferable.

Lower survival after right-sided versus left-sided colon cancers: Is an extended lymphadenectomy the answer?

INTRODUCTION: Tumour location may affect oncologic outcomes for colon adenocarcinoma due to different levels of vascular ligation and nodal harvest, but the data are equivocal. The objective of this study is to determine the effect of tumor location and lymph node yield on overall survival(OS) in stage I-III colon adenocarcinoma. METHODS: The 2004-2014 National Cancer Database was queried for colectomies for non-metastatic colon adenocarcinoma, excluding transverse colon and rectal cancer. Patients were grouped based on left/right tumor location. Main outcome measure was 5-year OS. Propensity score matching created balanced cohorts. Multilevel survival analysis determined the independent effect of tumor location and nodal harvest on OS. RESULTS: There were 504,958 patients (273,198 right; 231,760 left) in the entire cohort: 26.4% stage-I, 37.3% stage-II, and 36.3% stage-III (equal distribution left/right). After 1:1 matching(n = 297,080), right cancers were associated with worse 5-year overall survival for stage-II (66% vs. 70%, p < 0.001) and -III (56% vs. 60%, p < 0.001) despite similar nodal harvest and proportion receiving systemic therapy. On multivariate analysis, right-sided cancers (HR 1.12, 95%CI 1.06-1.19) had worse OS, independent of stage and nodal harvest. Nodal harvest ≥22 nodes had the highest OS (HR 0.71, 95%CI 0.68-0.75). There was an interaction between right-sided cancer and >22 lymph node harvest towards increased survival (HR 0.86, 95%CI 0.80-0.92). CONCLUSIONS: Right-sided cancers are associated with worse oncologic outcomes compared to left-sided tumors but a higher lymph node yield improves survival. These data provide indirect evidence for a higher lymphatic harvest to improve survival.

Double Incomplete Internal Biliary Fistula: Coexisting Cholecystogastric and Cholecystoduodenal Fistula.

Internal biliary fistula is a rare complication of a common surgical disease, cholelithiasis. It is seen in 0.74% of all biliary tract surgeries and is thought to be a result of repeated inflammatory periods of the gallbladder. In this report we present a case of incomplete cholecystogastric and cholecystoduodenal fistulae in a single patient missed by ultrasonography and endoscopic retrograde cholangiopancreatography and diagnosed intraoperatively. In the literature there is only one report of an incomplete cholecystogastric fistula. To our knowledge this is the first case of double incomplete internal biliary fistulae.

Mesothelial Cysts of the Round Ligament of the Uterus in 9 Patients: a 15-year experience.

Aim of this study was to evaluate the characteristic features of patients with mesothelial cyst of the round ligament of the uterus and the incidence of this entity. This was a retrospective review of 3065 patients who underwent inguinal exploration for groin mass from 1998 to 2013. Clinical, radiological and histopathological features of patients with a diagnosis of mesothelial cyst of the round ligament were analyzed. Of the 405 female patients reviewed 9 mesothelial cysts of the round ligament were identified (2.2%). The median age was 37 (range 19-82 years). In all patients the groin mass was manually irreducible on physical examination. The lesions were on the right side in 6 (66.6%) patients. These were identified before surgery in 4 (all by groin ultrasonography). Three were misidentified as a hernia before surgery. The remaining 2 (22%) had both hernia and the mesothelial cyst of the round ligament. The cysts were identified after surgery at the time of histopathological examination in these two patients. In all patients histopathological examination revealed multilobular cystic lesion lined by a single layer of mesothelial cells. Cystic lesions arising from the round ligament were identified and excised along with the round ligament in 7 patients. In the remaining 2, a hernia repair was also performed. There was no recurrence at follow-up. Mesothelial cysts of the round ligament are rare. They are easily misidentified as groin hernia. An accurate diagnosis requires a high index of suspicion and is greatly aided by preoperative imaging studies.