Radiographic staging practices of newly diagnosed colorectal cancer vary according to medical specialty.

BACKGROUND: Since 2008, multiple guidelines have endorsed incorporation of chest CT in the radiographic staging assessment of newly diagnosed colorectal cancer (CRC). Radiographic staging practices performed after CRC is detected have not been studied. OBJECTIVE: To evaluate radiographic staging practices for newly diagnosed CRC between gastroenterologists versus non-gastroenterologists. DESIGN: Observational cohort study. SETTING: Single, tertiary-care referral center. PATIENTS: Patients newly diagnosed with a T1 or higher stage CRC at time of colonoscopy between 2008 and 2013. INTERVENTIONS: Radiographic staging. MAIN OUTCOME MEASUREMENTS: Radiographic preoperative staging examinations ordered by gastroenterologists in comparison to those ordered by non-gastroenterology specialists. RESULTS: This study included 277 patients with CRC newly diagnosed by colonoscopy. There were 141 total ordering physicians (68 gastroenterologists and 73 non-gastroenterologists). The majority of preoperative radiographic staging was performed by gastroenterologists (59.2% of patients, n = 164). Colorectal surgeons managed staging in 28.7% of patients (n = 47). Gastroenterologists were more likely to omit a staging chest CT than were non-gastroenterologists (64.6% vs 46.9%; P < .001). Physician practice setting, rectal location of tumor, and advanced endoscopic appearance of tumors were predictors of chest CT inclusion. LIMITATIONS: Single center, moderate sample size of both providers and patients. CONCLUSION: Gastroenterologists more frequently ordered the initial radiographic staging studies in newly diagnosed CRC patients. However, gastroenterologists were less likely to include chest CT in the initial staging of CRC despite current guideline recommendations to do so. If confirmed with further studies, educational efforts to improve compliance and standardization may be needed.

Hospital readmission for fluid and electrolyte abnormalities following ileostomy construction: preventable or unpredictable?

BACKGROUND: Ileostomy creation has complications, including rehospitalization for fluid and electrolyte abnormalities. Although studies have identified predictors of this morbidity, readmission rates remain high. METHODS: The researchers conducted a retrospective chart review of all patients with ileostomy creation at a tertiary institution from January 2008 to June 2011. RESULTS: One hundred fifty-four patients (154) were included in this study; 71 (46.1 %) were female. Mean age was 49 ± 17.64 (range 16-91), and mean BMI was 26.9 ± 6.44 (range 13-52). The readmission rate for fluid and electrolyte abnormalities was 20.1 % for the study population; of those readmitted for all diagnoses, dehydration accounted for 40.7 % of all readmissions. Cancer was associated with readmission (χ(2) = 4.73, p = 0.03) as was neoadjuvant therapy (χ(2) = 9.20, p = 0.01). After multivariate analysis, only the use of anti-diarrheals and neoadjuvant therapy remained significant. High stoma output, adjuvant treatment, and postoperative complications were not significant. CONCLUSIONS: Our study found that the use of anti-diarrheals and neoadjuvant therapy for rectal cancer were associated with readmission. Our findings imply that the use of anti-diarrheals may be a marker for patients at risk for fluid and electrolyte abnormalities; these patients should be strictly monitored at home. Our study also suggests consideration of avoidance of ileostomy creation or different discharge criteria for at-risk patients. Prospective studies focused on stoma monitoring after discharge may help reduce rehospitalizations for fluid and electrolyte abnormalities after ileostomy creation.

Tumor scatter after neoadjuvant therapy for rectal cancer: are we dealing with an invisible margin?

BACKGROUND: After the impressive response of rectal cancers to neoadjuvant therapy, it seems reasonable to ask: can we can excise the small ulcer locally or avoid a radical resection if there is no gross residual tumor? Does gross response reflect what happens to tumor cells microscopically after radiation? OBJECTIVE: The aim of this study was to identify microscopic tumor cell response to radiation. DESIGN: This study is a retrospective review of a prospectively collected database. SETTING: This investigation was conducted at a single tertiary medical center. PATIENTS: Patients were selected who had elective radical resection for rectal cancer after preoperative chemotherapy and radiation performed by 2 colorectal surgeons between 2006 and 2011. MAIN OUTCOME MEASURES: The primary outcome measured was tumor presence after radiation therapy RESULTS: Of the 75 patients, 20 patients were complete responders and 55 had residual cancer. Of these patients, 28 had no tumor cells seen outside the gross ulcer, and 27 (49.1%) had tumor outside the visible ulcer or microscopic tumor present with no overlying ulcer. Of these tumors, 81.5% were skewed away from the ulcer center. The mean distance of distal scatter was 1.0 cm from the visible ulcer edge to a maximum of 3 cm; 3 patients had tumor cells more than 2 cm distal to the visible ulcer edge. Tumor scatter outside the ulcer was not associated with poor prognostic factors, such as nodal and distant disease, perineural invasion, or mucin; however, it was associated with lymphovascular invasion (χ2 = 4.12, p = 0.038) LIMITATIONS: There was limited access to clinical information gathered outside our institution. CONCLUSIONS: Our study suggests that 1) after radiation, the gross ulcer cannot be used to determine the sole area of potential residual tumor, 2) cancer cells may be found up to 3 cm distally from the gross ulcer, so the traditional 2-cm margin may not be adequate, and 3) local excision of the ulcer or no excision after apparent complete response appears to be insufficient treatment for rectal cancer.

Surgery after colonic stenting.

Colonic stenting is an accepted treatment of large bowel obstruction. The literature is sparse regarding surgical difficulties associated with an indwelling stent. We report our experience focusing on outcomes, complications, and whether the stent created intraoperative concerns. In this retrospective review, 6 patients were identified between 2007 and 2010 that had surgery after colonic stents were placed. Their charts were reviewed to compare clinical variables, surgical procedures, outcomes, and complications. One obstruction was due to diverticulitis. The stent reobstructed, leading to emergent transverse loop colostomy, and subsequent sigmoidectomy with stoma reversal. Four patients' obstructing masses were malignant. The final patient's stent was placed through a Hartmann's stump to drain a pelvic abscess. These 5 patients had no stent complications. Surgery occurred an average of 9.8 weeks after stent placement; four had low anterior resections and one underwent Hartmann's reversal. All 6 patients had colorectal anastomoses and five underwent laparoscopic surgery; one had an anastomotic leak requiring reoperation. Colonic stenting allows for the immediate relief of obstruction while permitting diagnosis and treatment of coexisting medical problems. The colon can be prepared for an elective rather than emergency operation, and a colostomy may be avoided.

Incisionless laparoscopic total proctocolectomy with ileal J-pouch anal anastomosis.

Minimally invasive surgery continues to evolve. Recent innovations have included single-incision access, robotic technology, and natural orifice dissection and/or specimen extraction. Many argue that there is minimal patient benefit to these advanced techniques. We report 39 patients undergoing laparoscopic ileal J-pouch anal anastomosis surgery, 17 of whom did not have a separate specimen extraction incision (Group 1). The specimen for this group was extracted through the circular incision made for the ileostomy; the pouch was constructed extracorporeally and returned to the abdomen through the stoma site. For the remaining 22 patients, a suprapubic Pfannenstiel incision was made (Group 2). No hand-assistance was used for either group. Group 1 showed a 45-minute reduction in operative time, a 1-day reduction in hospital stay, and a reduction in complications. Although these differences are modest, it shows that minimally invasive surgery is an evolving process. Small modifications may translate into significant advantages.

Laparoscopic colectomy: complications causing reoperation or emergency room/hospital readmissions.

The purpose of this study was to determine the incidence of complications causing reoperation or emergency room(ER)/hospital readmission after laparoscopic colectomy (LC). We retrospectively reviewed a prospectively managed database of 358 patients undergoing LC. Nonhand assisted LC was jointly performed by two surgeons assisted by a general surgery resident. Trochar site fascial wounds larger than 5 millimeters were not closed for the first 283 cases, mesenteric defects were not closed. Forty-one patients (11%) required reoperation. Of the 19 hernias (17 incisional, 2 mesenteric), seven caused early postoperative obstructions either within the first week of surgery or within 4 days after discharge. Twelve hernias presented in a delayed fashion and were repaired months later. Eight hernias occurred at trochar sites, nine at specimen extraction sites, and two were in the mesenteric defect. There were eight adhesive small bowel obstructions, five were treated with early reoperation. Other causes included perforations in six cases (2%), anastomotic leak in seven cases (2%) and bleeding in two cases (0.5%). Fifty-nine (16%) separate patients required evaluation in the ER. Fifty-three patients had one ER visit, six patients had two. Causes included nausea and vomiting in 19 cases (5%), wound infection in 16 cases (4%), pain in 13 cases (4%), fever in five cases (1%), thrombosis in four cases (1%); 46 were admitted to the hospital, 70 per cent were discharged within 4 days. Eleven per cent of patients required reoperation after LC, usually for hernias or adhesive small bowel obstruction. Fifty-three per cent of the hernias could have been avoided by routine closure of the fascia. An additional 16 per cent of patients required ER evaluation for complications. Of these, 78 per cent were admitted, 70 per cent were discharged within 4 days. LC is not without potential complications and is not necessarily a less morbid operation.

Apoptosis and inflammation: role of adipokines in inflammatory bowel disease.

OBJECTIVES: Leptin and adiponectin (APN) are adipokines produced by adipocytes that participate in the modulation of immune and inflammatory responses. In Crohn's disease (CD), fat wrapping surrounding the inflamed intestine produces high levels of leptin and APN. In inflammatory bowel disease (IBD), apoptosis resistance of lamina propria T lymphocytes (LPL-T) is one of the mechanisms that maintains chronic inflammation. We addressed the mechanism by which leptin and APN regulate inflammation and apoptosis in IBD. METHODS: Immune cell infiltration, several factors expressed by adipose tissue (AT), and spontaneous release of cytokines by adipocytes were measured. The presence of APN and leptin in intestinal mucosa was detected and their effect on LPL-T apoptosis, signal transducer and activator of transcription 3 (STAT3), Suppressor of Cytokine Signaling 3 (SOCS3), Bcl-2 and Bcl-xL expression, and cytokine production was studied. In addition, the effects of globular and high-molecular-weight (HMW) APN on LPL-T cytokine production and apoptosis were studied. RESULTS: Higher levels of several chemokines, cytokines, and growth factors were present in AT near active than near inactive disease. A significantly higher amount of inflammatory infiltrate was present in AT near active CD than near ulcerative colitis, controls, and near the inactive area of CD. There were no changes in the ratios of APN molecular weight in control and IBD adipocyte products. Leptin and APN inhibited anti-CD3-stimulated-LPL-T apoptosis and potentiated STAT3 phosphorylation, Bcl-2, and Bcl-xL expression in IBD and control mucosa. However, SOCS3 expression was suppressed only in IBD. Both globular and HMW APN have similar effects on LPL-T cytokine production and apoptosis. Leptin and APN enhanced interleukin (IL)-10 production by anti-CD3-stimulated LPL-T in IBD only. APN, but not leptin, increased anti-CD3-induced IL-6 levels in LPL-T only in IBD patients. IL-10 exerts its anti-inflammatory activity in the presence of SOCS3 suppression by leptin or APN. CONCLUSION: Leptin and APN maintain the inhibition of anti-CD3-stimulated LPL-T apoptosis by enhancing Bcl-2 and Bcl-xL overexpression and promoting STAT3 phosphorylation while suppressing SOCS3.

Morbidity and mortality in octogenarians and older undergoing major intestinal surgery.

PURPOSE: The elderly constitute an increasing portion of the world's population. Our study assessed morbidity, mortality, and outcome in octogenarians who have undergone lower intestinal operations, and compared outcome between subsequent decades. METHODS: A total of 138 octogenarians who underwent 157 operations were retrospectively studied (1995-2005). The American Society of Anesthesiologists Physical Status classification, blood loss, length of surgery, surgical intensive care unit admission, length of surgical intensive care unit and hospital stay, and complications were recorded. Emergency vs. elective and cancer vs. noncancer cases were compared. Results were compared for the years 1985 to 1994. RESULTS: Cancer comprised 63 percent of cases. The most common causes of mortality were sepsis and multiorgan failure. Differences (P < 0.05) were found for elective vs. emergent surgeries according to age, length of stay, complications, surgical intensive care unit admission, American Society of Anesthesiologists Physical Status classification, and mortality. Noncancer cases were more likely to be emergent, have a higher American Society of Anesthesiologists Physical Status classification, and a higher mortality rate. When emergency operations were excluded, there were no significant differences between cancer vs. noncancer cases. In a comparison of two decades (1985-1994 vs. 1995-2005), we found that the mortality rate in patients younger than aged 85 years decreased by more than 10 percent (P < 0.05). Patients older than aged 85 years demonstrated no significant differences between decades. The strongest determinants of outcome are emergency status and the presence of comorbid conditions. CONCLUSIONS: Elective surgery in the elderly is safe. Emergency surgery is accompanied by significant morbidity and mortality.

Preoperative considerations and creation of normal ostomies.

Stomas provide fecal diversion in emergent and elective settings. Preoperative planning and counseling are extremely important to the creation of an acceptable and functional ostomy for the surgeon and patient. Proper site selection will help decrease the incidence of postoperative complications. Ileostomy, colostomy, and cecostomy indications and techniques are discussed.

Laparoscopic rectopexy without resection: a worthwhile treatment for rectal prolapse in patients without prior constipation.

Anterior resection with rectopexy is considered by many to be the best operation for rectal prolapse. It is feared that if sigmoid redundancy created by rectal mobilization is not resected, colonic motility (specifically constipation) could be disabling. We contend that resection is not necessary in patients without preexisting constipation. We tested this hypothesis using a laparoscopic approach to minimize hospital stay. Twelve patients were treated (eight women); mean age was 45 years (range, 25-82 years). No patient had preexisting constipation; one had irritable bowel syndrome. Three patients had prior prolapse operations. Full rectal mobilization was undertaken down to the levator hiatus; neither the mesenteric vessels nor the lateral ligaments were divided. Rectopexy to the presacral fascia was done with one to two Nurolon sutures on either side of the rectum. There were no complications; mean hospital stay was 4 days. Mean follow up was 32 months (range; 3-75 months); there have been no recurrences. Only the patient with irritable bowel syndrome developed significant constipation. We conclude: 1) rectopexy can be safely done laparoscopically, 2) resection is not required in the absence of prior constipation, and 3) rectal mobilization and rectopexy does not predispose to future constipation in these selected patients.

Hartmann's colostomy reversal: outcome of patients undergoing surgery with the intention of eliminating fecal diversion.

Reversal of a Hartmann's operation can be a morbid undertaking; successful restoration of intestinal continuity cannot be guaranteed. Between June 2001 and July 2006, 35 Hartmann's reversals were undertaken. There were 19 males (54%). Mean age was 54.7 years (range, 14-82 years). Twenty-one (60%) patients had their Hartmann's for diverticular disease, 7 (20%) for anorectal cancer, 4 (11%) for volvulus, and 3 for miscellaneous reasons. Mean length of stay was 7.7 days (range, 3-16 days); 23 per cent required intensive care for a mean 2.3 days (range, 1-4 days). Blood loss was 470 mL, and mean operative time was 4.28 hours (range, 1-8.3 hours). The mean time interval between the original operation and its reversal was 8.9 months (range, 1.4-55 months). Extensive lysis of adhesions was required in 69 per cent, 40 per cent experienced minor complications (urinary tract infections, ileus, and so on), and 38 per cent had major complications (myocardial infarction, leak, hernias, respiratory failure). There was one death (3%). The operation failed because of intraoperative circumstances in three patients (8%). Ten patients (26%) had stomas at the time of discharge of which 3 were intended to be permanent and 7 were temporary. Of the latter, 3 were successfully closed, 3 are awaiting closure, and 1 had complete anastomotic failure requiring permanent diversion. Total failure rate was 10.3 per cent; contributing factors included prior radiation and ultra-low anastomoses.

Patient attitudes toward medical students in an outpatient colorectal surgery clinic.

PURPOSE: Patients with colorectal diseases may be reluctant to have medical students present during their outpatient clinic visit, especially when significant disrobing and embarrassing examinations are performed. This study examines patient attitudes in this regard. METHODS: One hundred consecutive patients completed a questionnaire after the conclusion of their office visit. Patient age, gender, race, diagnosis, level of disease, socioeconomic status, and education level were recorded as well as attitudes toward the presence of students in the examination room. Responses were analyzed by using two-sample Z tests or chi-squared tests for comparison of proportions among groups. The pooled-variance t-test was used to compare the difference of means when appropriate. RESULTS: Overall, 81 percent of patients accepted students' presence. Females were less likely than males (77 vs. 86 percent; P = 0.03) and blacks less likely than whites (61 vs. 88 percent; P = 0.004) to accept students. Higher compliance was demonstrated in patients with greater perceived severity of disease (P = 0.03). We found no significant correlation between patient level of education or income and their comfort level with respect to teaching in the examination room. However, racial differences were seen in this category (P = 0.01). Females were more likely to prefer the same gender student, but this was not statistically significant. CONCLUSIONS: Students are generally accepted in outpatient colorectal clinics (81 percent). Reasons for acceptance of students included being able to contribute to the teaching of future doctors. Reasons for refusal included perceived increased length of the office visit and patient privacy. We noticed significant differences in compliance by gender, race, and severity of disease, but not age, patient level of income, or education.

Apoptosis resistance in ulcerative colitis: high expression of decoy receptors by lamina propria T cells.

Intestinal mucosa is constantly exposed to normal environmental antigens. A significant number of intestinal mucosal T cells are being deleted through apoptosis. In contrast, T cells from inflamed mucosa of ulcerative colitis patients did not undergo apoptosis. In this study, we determined whether the apoptosis of normal mucosal T cells was induced by antigen receptor stimulation and further determined pathways that mediated the apoptosis. Freshly isolated lamina propria T cells were stimulated with CD3 mAb and apoptosis was determined by Annexin V staining. Normal mucosal T cells underwent apoptosis upon CD3 mAb stimulation whereas the T cells from inflamed mucosa did not. The apoptosis in normal T cells was blocked by TRAIL-R1:Fc and an inhibiting CD95 antibody. Interestingly, decoy receptor (DcR)1, DcR2, and DcR3 that compete with death receptor (DR)4/5 and CD95 were highly expressed by the T cells from inflamed mucosa, but much lower by T cells from normal mucosa. Our data suggest that normal mucosal T cells are constantly deleted in response to environmental antigens mediated through DR4/5 and CD95 pathways and mucosal T cells from ulcerative colitis resist to undergoing apoptosis due to highly expression of DcR1, DcR2, and DcR3.

Preoperative evaluation and oncologic principles of colon cancer surgery.

Colorectal cancer is the third most common malignancy in men and women and accounts for 10% of all cancer deaths. The primary risk factor for colorectal cancer is advancing age, but other factors also play a role in its development, including genetic predisposition, smoking, alcohol consumption, obesity, and high-fat, low-fiber diet. Colon cancer survival is primarily related to the stage of disease at diagnosis. The main screening tests for colon cancer are fecal occult blood testing, flexible sigmoidoscopy, double-contrast barium enema, and colonoscopy. The pre-operative evaluation should include a complete blood count, carcinoembryonic antigen (CEA), colonoscopy, and chest radiograph. Other preoperative evaluations are patient specific or of unproven benefit. The operative procedure should include a bowel preparation, parenteral antibiotics, and deep venous thrombosis prophylaxis. The procedure performed must be tailored to the location of the colon cancer but should include complete, en bloc resection of the cancer and its lymphatic drainage, including locally invaded structures. The bowel margins of resection should be at least 5 cm from the tumor to minimize anastomotic recurrences. Laparoscopic colectomy has been shown to be as safe and effective as open colectomy for the treatment of colon cancer. The use of sentinel lymph node biopsy is feasible but has not yet been proved clinically useful. Surveillance after surgery for colon cancer is necessary to monitor for metastatic disease or local recurrence. Several groups have made surveillance recommendations including office visits, colonoscopy, and CEA monitoring.

Anal complications after restorative proctocolectomy (J-pouch).

A prospective assessment was performed to determine the incidence of anal complications after ileoanal J-pouch anastomosis procedures for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). From 1989 to 2000, 75 patients (50 male and 25 female) underwent proctocolectomy and ileal pouch-anal anastomosis with temporary loop ileostomy for UC (N = 68) and FAP (N = 7). Overall 33 patients (44%) developed anal complications postoperatively. Nineteen patients (25%) had mild anal stenosis amenable to digital dilatation in the office. Ten patients (13%) had severe anal stenosis requiring operative dilatation. Ileostomy closure was delayed longer than 3 months in four patients because of anal stenosis. One patient never had his ileostomy closed secondary to severe anal stenosis. Anal fissures developed in one patient that resolved with conservative treatment. Three patients developed fistula-in-ano and one patient developed a pouch-vaginal fistula. Of these four patients two later manifested signs of Crohn's disease. Four patients developed perirectal abscesses (three without fistulas) that were treated with incision and drainage. Two patients had presacral (anastomotic) abscesses; one patient was treated with temporary anastomotic diversion and the other underwent a permanent ileostomy and pouch resection. Both of these patients were later diagnosed with Crohn's disease. Anal complications developed in 17 of 41 (41%) handsewn anastomoses, 16 of 34 (47%) stapled anastomoses, three of seven (43%) patients with FAP, and 30 of 68 (44%) patients with UC. Operative technique and disease type did not significantly correlate with the type of anal complication. However, hand-sewn anastomoses had a higher incidence of severe strictures and FAP patients did not develop anal abscesses, fistulas, or fissures. Forty-five per cent of our patients with abscesses/fistulas and all of our patients with presacral abscesses from anastomotic dehiscence were later diagnosed with Crohn's disease. Anal complications after ileoanal J-pouch anastomosis are relatively common.