Neoadjuvant botensilimab plus balstilimab response pattern in locally advanced mismatch repair proficient colorectal cancer.

In patients with locally advanced cancer without distant metastases, the neoadjuvant setting presents a platform to evaluate new drugs. For mismatch repair proficient/microsatellite stable (pMMR/MSS) colon and rectal cancer, immunotherapy has shown limited efficacy. Herein, we report exceptional responses observed with neoadjuvant botensilimab (BOT), an Fc-enhanced next-generation anti-CTLA-4 antibody, alongside balstilimab (BAL; an anti-PD-1 antibody) in two patients with pMMR/MSS colon and rectal cancer. The histological pattern of rapid immune response observed ("inside-out" (serosa-to-mucosa) tumor regression) has not been described previously in this setting. Spatial biology analyses (RareCyte Inc.) reveal mechanisms of actions of BOT, a novel innate-adaptive immune activator. These observations have downstream implications for clinical trial designs using neoadjuvant immunotherapy and potentially sparing patients chemotherapy.

The SAGES MASTERS program presents: the top 10 seminal articles for laparoscopic left and sigmoid colectomy pathway for uncomplicated disease.

BACKGROUND: As one of the 8 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program clinical pathways, the Colorectal Pathway aims to deliver educational content for the general surgeon organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure. In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic left/sigmoid colectomy for uncomplicated disease. METHODS: Using a systematic literature search of Web of Science, the most cited articles on laparoscopic left and sigmoid colectomy were identified, reviewed, and ranked by members of the SAGES Colorectal Task Force. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, including their findings, strengths and limitations with emphasis on relevance and impact in the field. RESULTS: The top 10 articles selected focus on variations in minimally invasive surgical techniques, video demonstrations, stratified approaches for benign and malignant disease as well as assessments of the learning curve. CONCLUSIONS: The selected top 10 seminal articles for laparoscopic left and sigmoid colectomy in uncomplicated disease are considered by the SAGES colorectal task force to be fundamental to the knowledge base of minimally invasive surgeons as they progress to mastery in these procedures.

Rectal Prolapse Repair with Abdominal Fixation Under Sedation and Local or Epidural Anesthesia: Prospective Pilot Study in 10 Elderly Subjects.

Background: Rectal prolapse (RP) is primarily a disease of the elderly, where treatment may be associated with significant postoperative morbidity including that related to anesthesia. Objective: The aim of this study was to evaluate the safety and feasibility of a novel abdominal approach to RP repair under sedation and local anesthesia and to assess short- and long-term clinical outcomes in elderly patients (>70 years). Design Settings: This is a prospective pilot study with 10 patients using a novel RP repair. The anesthesia type was local or epidural with sedation. Follow-up was done at 30 days, 12, and 24 months. Patients: Patients were men and women >70 years of age with RP. Main Outcome Measures: (1) Feasibility: successful completion of RP repair using the novel abdominal approach with laparoscopic assistance. (2) Safety: safety was measured by the incidence of the intraoperative complications (bowel perforation, organ injury, and bleeding requiring blood transfusion). (3) Sedation and local anesthesia feasibility: surgery was safely completed without patient intubation. Results: Ten female patients >70 years of age underwent RP repair using the novel abdominal approach. General anesthesia was not required in any of the 10 patients. Two patients recurred within 6 months. One of the patients with recurrence of RP subsequently underwent laparoscopic rectopexy, and the other was minimal and required no further treatment. One mortality occurred at 3 months unrelated to the procedure. No other anesthetic or surgical intraoperative and postoperative complications were observed. Limitations: This is a single-institution pilot study. Conclusions: Abdominal RP repair under sedation and regional anesthesia appears feasible and safe in elderly patients and may, in the future, provide an effective alternative to current treatment options for RP, avoiding general anesthesia. ClinicalTrial.gov registration number: NCT01980043.

Evaluation of Trends in the Use of InterStim for Fecal Incontinence.

BACKGROUND: Fecal incontinence (FI) represents a large source of morbidity and is a challenging clinical problem to manage. InterStim was approved to treat FI in 2011. Little is known about its adoption. We sought to characterize patterns of use of Interstim since Food and Drug Administration approval for FI. METHODS: The New York State SPARCS database was used to evaluate InterStim use for FI from 2011 to 2014. The primary endpoint was the number of successful implantations of InterStim. Secondary endpoints included device removal, median time to removal of device, 90-day infection rates, and percentage of procedures performed by surgeon specialty and geographic location. RESULTS: A total of 369 patients with FI underwent "Stage 1" of InterStim from 2011 to 2014. A total of 302 patients underwent "Stage 2," yielding a trial period failure rate of 18.2%. The majority of patients who underwent successful implantation were female (87.7%) and White (78.8%). Twenty-nine patients underwent device removal after a median duration of 147 days. Estimated risk of removal at median follow-up of 2 years was 11.8%. Colorectal surgeons comprised 51.1% of all providers followed by gynecologic (24.4%) and urologic surgeons (17.8%). A total of 71.7% of providers performed <5 procedures, while 3 of the highest volume providers performed 50.7% of all procedures. CONCLUSIONS: InterStim for FI has been used by a wide variety of providers in New York State although only a few high-volume providers have performed the majority of procedures. White, female patients with Medicare are the most common recipients of InterStim. Further work must be done to develop strategies for improving access to this technology and to determine whether volume relates to outcomes.

Combined Endoscopic and Laparoscopic Surgery.

Benign colon polyps are best treated endoscopically. Colon polyps that are not amenable for endoscopic removals either because they are too large or situated in anatomically difficult locations can pose a clinical dilemma. Traditionally the most common recommendation for these patients has been to offer a colon resection. Although the laparoscopic approach has improved short-term outcomes, morbidities associated with bowel resection are still significant. We may be over treating majority of these patients because of the remote possibility that these polyps may be harboring a cancer. A combined approach using both laparoscopy and colonoscopy (combined endoscopic and laparoscopic surgery) has been described as an alternative to bowel resection in select patients with polyps that cannot be removed endoscopically. Polyp removal using this combined approach may be an effective alternative in select patients.

Disparities in the Use of Sacral Neuromodulation among Medicare Beneficiaries.

PURPOSE: Sacral neuromodulation with the InterStim® has been done to treat urinary and bowel control. There are limited data in the literature on use trends of sacral neuromodulation. We explored disparities in use among Medicare beneficiaries. MATERIALS AND METHODS: We queried a 5% national random sample of Medicare claims for 2001, 2004, 2007 and 2010. All patients with an ICD-9 diagnosis code representing a potential urological indication for sacral neuromodulation were included. Patients who underwent device implantation were identified using CPT-4 codes. Statistical analysis was done with the chi-square and Fisher tests, and multivariate logistic regression using software. RESULTS: A total of 2,322,060 patients were identified with a diagnosis that could potentially be treated with sacral neuromodulation. During the 10-year study period the percent of these patients who ultimately underwent implantation increased from 0.03% to 0.91% (p <0.0001) for a total of 13,360 (0.58%). On logistic regression analysis women (OR 3.85, p <0.0001) and patients younger than 65 years (OR 1.00 vs 0.29 to 0.39, p <0.0001) were more likely to be treated. Minority patients (OR 0.38, p <0.0001) and those living in the western United States (OR 0.52, p <0.0001) were less likely to receive treatment. CONCLUSIONS: Sacral neuromodulation use significantly increased among Medicare beneficiaries in a 10-year period. Patients were more likely to be treated with sacral neuromodulation if they were female, white, younger (younger than 65 years) and living outside the western United States.

Dynamic article: long-term outcomes of patients undergoing combined endolaparoscopic surgery for benign colon polyps.

BACKGROUND: Patients with large benign colon polyps not amenable to endoscopic removal commonly undergo resections. Polyp removal using combined endolaparoscopic surgery may be an effective alternative to bowel resection in select patients. OBJECTIVE: The aim of this study was to evaluate short-term and long-term outcomes of patients who underwent endolaparoscopy at our institution. DATA SOURCES: Medical records and a prospectively maintained database were reviewed. STUDY SELECTION: This study constituted a retrospective review of consecutive patients who underwent endolaparoscopy for benign polyps from 2003 to 2012. INTERVENTIONS: Combined endolaparoscopic surgery was performed. MAIN OUTCOME MEASURES: The primary outcomes measured were success rate, rate of recurrence, rate of malignancy, length of stay, and complication rate. RESULTS: A total of 75 patients were taken to the operating room with the intention of endolaparoscopy. The most common indications were large polyp size and difficult location. Based on intraoperative findings, 10 patients were suspected of having cancer and underwent immediate laparoscopic colectomy. Of 65 attempted cases, 48 patients (74%) underwent successful combined endolaparoscopic surgery. Median follow-up time was 65 (8-87) months. Patients in whom combined endolaparoscopic surgery was unsuccessful were converted to colectomy (2 open, 15 laparoscopic). Two patients were converted because of concerns of cancer and 15 because of technical difficulties. Median operative time for successful endolaparoscopy was 145 (50-249) minutes. The complication rate was 4.4% (2/48). Median length of stay was 1 (0-6) day for endolaparoscopy vs 5 (3-19) days for those converted to colectomy. Median polyp size was 3 (1.0-7.0) cm. One patient was found to have cancer on final pathology, but refused to have further surgery. Sensitivity and specificity of predicting malignancy based on clinical findings were 33% (4/12) and 98.5% (64/65). Four of 5 patients who had recurrence (10%) after endolaparoscopy had complete endoscopic polypectomy. One patient required delayed laparoscopic colectomy for a second recurrence. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Combined endolaparoscopic surgery appears to be a safe and effective alternative to colectomy in all parts of the colon in patients who have benign polyps not removable with colonoscopy alone.

History of hysterectomy: a significant problem for colonoscopists that is not present in patients who have had sigmoid colectomy.

PURPOSE: During colonoscopy, it is often difficult to traverse the sigmoid colon in patients who have had a hysterectomy, presumably due to postsurgical pelvic adhesions. We performed this study to document this difficulty and to determine whether sigmoid colectomy prevents it. METHODS: Data were acquired from a single endoscopist's prospective database. Colonoscopies performed in women were grouped according to history of hysterectomy and/or sigmoid colectomy. Groups were compared for colonoscopy completion rate, medication used, and time of examination. Participation of fellows and rate of complications were recorded. Patients with a history of abdominal-perineal resection of the rectum were excluded. RESULTS: From 1989 to 2006, a total of 4116 colonoscopies were performed in women: 993 had undergone hysterectomy (24.1%), of whom 108 (10.9%) had also undergone sigmoid colectomy. There were 3123 exams in woman who had their uterus (75.9%); 320 (10.2%) had undergone sigmoid colectomy. Patients who still had a sigmoid colon but had a history of hysterectomy had significantly lower colonoscopy completion rates (89.2%) and significantly longer mean examination time (28.9 +/- 12.3 minutes), and more of them required sedation with benzodiazepines (88.7%) than the other groups (P < .05). Fellow participation increased time of colonoscopy and complications were more frequent in patients with hysterectomy. CONCLUSION: Posthysterectomy adhesions to the sigmoid colon make colonoscopy more difficult and more painful. These adverse effects are not present in hysterectomized women who have undergone sigmoid resection.

Outcome of salvage surgery for ileal pouches referred with a diagnosis of Crohn's disease.

INTRODUCTION: Technical complications after ileal pouch-anal anastomosis may be mislabeled as Crohn's disease. The purpose of our study is to evaluate the presentation, treatment, and outcomes of patients with a potential misdiagnosis of Crohn's disease who have undergone redo ileal pouch-anal anastomosis. METHODS: We evaluated a historical cohort of patients, initially referred from outside institutions with a diagnosis of Crohn's disease of the pouch, who subsequently had redo ileal pouch-anal anastomosis (redo pouch or pouch revision for pouch failure) at our institution. With the use of validated questionnaires, the functional outcomes and quality of life of this cohort were compared with a control group of patients who underwent primary ileal pouch-anal anastomosis to assess whether a change in the diagnosis from Crohn's disease to technical complications was appropriate. RESULTS: Thirty-three patients underwent a redo pouch procedure for a previous diagnosis of Crohn's disease of the pouch. Precolectomy diagnosis included ulcerative colitis (31 patients) and indeterminate colitis (2 patients). Findings on our further evaluation and subsequent indications for repeat pouch surgery included pouch fistula (20 patients), pelvic sepsis or anastomotic leak (17 patients), stricture (4 patients), refractory pouchitis (2 patients), long exit conduit (1 patient), and retained rectal stump (1 patient). All patients had medical treatment for Crohn's disease before referral. Median time between primary and redo pouch was 2.1 years (interquartile range, 1.8-4.9). Median follow-up was 1.7 years (interquartile range, 1.0-3.5). Pouch retention rate was 84.8%. Five patients (15.2%) had pouch failure. Seven patients (21.2%) ultimately had pathology consistent with Crohn's disease. Comparison of the redo pouch and control groups revealed that functional outcomes and quality of life were similar between groups. CONCLUSION: Patients identified as having Crohn's disease need to be carefully reevaluated because some of these patients may actually have surgery-associated complications and can have a favorable long-term outcome after redo ileal pouch-anal anastomosis.

Gastro-broncho-pleural fistula after laparoscopic gastric band placement.

Laparoscopic gastric band placement is a common procedure for morbid obesity. Common complications include gastric perforation, band erosion, and band slippage. We present the first report in the literature of gastro-bronchial-pleural fistula after laparoscopic gastric band placement.

A single training center's experience with 200 consecutive cases of diverticulitis: can all patients be approached laparoscopically?

BACKGROUND: This study aimed to evaluate the outcomes for consecutive patients with diverticular disease who underwent elective laparoscopic sigmoid colectomy. METHODS: Data for this patient population were collected by chart review and analyzed retrospectively. RESULTS: Between December 2001 and March 2007, 200 consecutive patients (93 men and 107 women) with an average age of 55 years were identified. All cases were managed by one of two colorectal surgeons. Of the 200 patients, 158 had recurrent diverticulitis, 20 had fistulas, 12 had abscesses, 8 had strictures, 1 had a mass, and 1 had a bleed. The mean operative time was 159 min, and the conversion rate was 8%. A total of 30 early postoperative complications occurred for 26 patients including wound infection (n = 9), ileus (n = 8), Clostridium difficile colitis (n = 3), urinary retention (n = 3), pelvic abscess (n = 2), deep vein thrombosis and pulmonary embolism (n = 1), pneumonia (n = 1) urinary tract infection (n = 1), anastomotic leak (n = 1), and small bowel obstruction (n = 1). Late complications experienced by 11 patients included Clostridium difficile colitis (n = 3), incisional hernia (n = 3), wound infection (n = 3), wound hematoma (n = 1), and intraabdominal hemorrhage (n = 1). CONCLUSIONS: The authors believe it is feasible to offer elective laparoscopic sigmoid colectomy to all patients with symptomatic diverticular disease despite preoperative risk factors.