Pediatric Colorectal Surgery: A Collaborative Approach From a Single Institution.

BACKGROUND: Inflammatory bowel disease encompasses relapsing gastrointestinal disorders commonly presenting in pediatric patients, with 25% of diagnoses made before age 20 and 4% before age 5. Considering the need for life-long surgical follow-up, a collaborative system involving both pediatric and colorectal surgeons could improve overall patient experiences. We hypothesized that cases performed in collaboration with both pediatric and adult colorectal surgeons may lead to better outcomes. METHODS: Data were gathered retrospectively for 116 patients 18 y old or younger who underwent colorectal resections for inflammatory bowel disease between 2010 and 2017 at our institution. Data included patient demographics, type of procedure, surgical approach, specimen extraction site, surgeon involvement (pediatric, colorectal, or collaborative), operative time, and estimated blood loss. We analyzed days until passage of flatus and bowel movement, length of stay, type of surgical procedure, and surgical complications. RESULTS: Our data showed that days until flatus (2.27 ± 0.47, P = 0.049), first bowel movement (2.64 ± 0.67, P = 0.006), and length of stay (4.45 ± 1.51, P = 0.006) were the shortest in the collaborative group. We also found that single-incision laparoscopic surgery was significantly more common in the collaborative group (77.8%, P = 0.002). We did not see a difference in surgical complication rates among any of the groups. CONCLUSIONS: Our study showed short-term beneficial outcomes in a single institution associated with the collaboration of pediatric surgeons and colorectal surgeons on pediatric colorectal cases in comparison to those performed by pediatric surgeons or adult colorectal surgeons alone.

Clinically Node Negative, Pathologically Node Positive Rectal Cancer Patients Who Did Not Receive Neoadjuvant Therapy.

PURPOSE: Neoadjuvant chemoradiotherapy is the preferred standard of care for clinical stages II-III rectal cancer. It is uncertain whether clinically node negative (cN-) tumors found to be pathologically stage III could be optimally treated with surgery alone and avoid adjuvant treatments. The aim of our study was to define the outcomes of such patients. METHODS: Patients undergoing radical surgery using total mesorectal excision (TME) techniques for rectal cancer (≤12 cm from the anal verge) with curative intent during 2000-2012 and found to have stage III disease on final pathology were identified from a prospectively maintained database. Patients were staged with abdominopelvic CT, transrectal endoscopic ultrasound, and/or pelvic MRI. Exclusion criteria were cN+ without neoadjuvant chemoradiotherapy, hereditary colorectal syndromes, inflammatory bowel diseases, lack of preoperative nodal staging, intraoperative radiotherapy, and follow-up <3 years. We compared cN-/pN+ patients according to the postoperative treatment received (group 1 if no further treatment, group 2 if any postoperative treatments), using ypN+ patients (neoadjuvant chemoradiotherapy + surgery) as controls (group 3). Oncological outcomes evaluated included overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), local recurrence (LR), and distant recurrence (DR). RESULTS: Out of 218 patients included in the study, 77 cN- patients underwent initial surgery with a pN+ surgical specimen. Eighteen of these patients received no postoperative treatment due to associated comorbidity, patient preference, or postoperative complications while the remaining 59 (group 2) patients received chemoradiotherapy (n = 21) or chemotherapy alone (n = 38), respectively, and group 3 included 141 patients. Distal, radial resection margins and TME grading when available were comparable among groups. cN-/pN+ patients treated with surgery alone were associated with significantly poorer cancer outcomes compared with cN-/pN+ patients who received any form of adjuvant therapy and to ypN+ patients. CONCLUSION: TME surgery is not sufficient to optimize outcomes among rectal cancer patients believed to be node negative and found to be stage III based on specimen pathology.

Impact of the Specific Extraction-Site Location on the Risk of Incisional Hernia After Laparoscopic Colorectal Resection.

BACKGROUND: The impact of the specific incision used for specimen extraction during laparoscopic colorectal surgery on incisional hernia rates relative to other contributing factors remains unclear. OBJECTIVE: This study aimed to assess the relationship between extraction-site location and incisional hernia after laparoscopic colorectal surgery. DESIGN: This was a retrospective cohort study (January 2000 through December 2011). SETTINGS: The study was conducted at a high-volume, specialized colorectal surgery department. PATIENTS: All of the patients undergoing elective laparoscopic colorectal resection were identified from our prospectively maintained institutional database. MAIN OUTCOME MEASURES: Extraction-site and port-site incisional hernias clinically detected by physician or detected on CT scan were collected. Converted cases, defined as the use of a midline incision to perform the operation, were kept in the intent-to-treat analysis. Specific extraction-site groups were compared, and other relevant factors associated with incisional hernia rates were also evaluated with univariate and multivariate analyses. RESULTS: A total of 2148 patients (54.0% with abdominal and 46.0% with pelvic operations) with a mean age of 51.7 ± 18.2 years (52% women) were reviewed. Used extraction sites were infraumbilical midline (23.7%), stoma site/right or left lower quadrant (15%), periumbilical midline (22.5%), and Pfannenstiel (29.6%) and midline converted (9.2%). Overall crude extraction site incisional hernia rate during a mean follow-up of 5.9 ± 3.0 years was 7.2% (n = 155). Extraction-site incisional hernia crude rates were highest after periumbilical midline (12.6%) and a midline incision used for conversion to open surgery (12.0%). Independent factors associated with extraction-site incisional hernia were any extraction sites compared with Pfannenstiel (periumbilical midline HR = 12.7; midline converted HR = 13.1; stoma site HR = 28.4; p < 0.001 for each), increased BMI (HR = 1.23; p = 0.002), synchronous port-site hernias (HR = 3.66; p < 0.001), and postoperative superficial surgical-site infection (HR = 2.11; p < 0.001). LIMITATIONS: This study was limited by its retrospective nature, incisional hernia diagnoses based on clinical examination, and heterogeneous surgical population. CONCLUSIONS: Preferential extraction sites to minimize incisional hernia rates should be Pfannenstiel or incisions off the midline. Midline incisions should be avoided when possible.

Impact of tumor location on lymph node metastasis in T1 colorectal cancer.

PURPOSE: Data evaluating the risk of lymph node metastasis depending upon the location of the primary tumor are limited in patients with T1 colorectal cancer. We aimed to evaluate the impact of tumor location on lymph node metastasis in T1 colorectal cancer. METHODS: Patients who underwent an oncologic resection with curative intent for T1 adenocarcinoma of the colon and rectum between January 1997 and October 2014 were assessed. Exclusion criteria were distant organ metastases, previous or concurrent cancer, past history of surgical or medical cancer treatment, preoperative chemoradiation, and patients with inflammatory bowel disease or polyposis syndromes. RESULTS: Out of 232 (56 % male) patients fulfilling the study criteria, 24 (10 %) had lymph node metastasis. Age (65 vs 61 years, p = 0.1), gender (55 vs 63 % male, p = 0.5), tumor size (2 vs 2 cm, p = 0.49), and lymphovascular invasion (5 vs 8 %, p = 0.46) were not associated with lymph node metastasis. While there was no statistical significance (p = 0.2), lymph node positivity was higher in rectal cancer (14 %, n = 11/79) compared to colon cancer (9 %, n = 13/153). CONCLUSIONS: Although it was not statistically significant, lymph node positivity varies based on tumor location of T1 colorectal adenocarcinoma regardless of fundamental tumor characteristics including size, differentiation, and lymphovascular invasion.

Case-matched Comparison of Robotic Versus Laparoscopic Colorectal Surgery: Initial Institutional Experience.

Robotic colorectal surgery is an emerging technique. In this study, we aimed to compare outcomes of robotic colorectal operations to laparoscopy. Patients undergoing robotic colorectal surgery between November 2010 and July 2013 were case matched to laparoscopic counterparts based on diagnosis and operation type. Perioperative and short-term postoperative outcomes were compared. There were 57 patients who underwent robotic colorectal surgery. American Society of Anaesthesiologists score was higher in patients who underwent robotic surgery (2 vs. 3, P=0.01). Blood loss (200 vs. 300 mL, P=0.27) and conversion rate to open surgery (6 vs. 5, P=0.75) were similar between the groups. Operating time was longer in robotic surgery (172 vs. 267 min, P<0.0001). Time to first bowel movement (3 vs. 3 d, P=0.38), hospital stay (5 vs. 6 d, P=0.22), and postoperative complications were comparable between the groups. In the early learning curve period, robotic colorectal surgery shows similar short-term outcomes with longer operating time compared with conventional laparoscopy.

Hand-Assisted versus Straight-Laparoscopic versus Open Proctosigmoidectomy for Treatment of Sigmoid and Rectal Cancer: A Case-Matched Study of 100 Patients.

To assess the efficacy of laparoscopic proctosigmoidectomy for cancer treatment, 25 patients who underwent hand-assisted laparoscopic resection during the study period (9/2006 - 7/2012) were matched to 25 straight-laparoscopic and 50 open-surgery cases. The patients who underwent hand-assisted resection had higher rates of preoperative cardiac disease and hypertension than did the straight-laparoscopy and open-surgery groups. Straight-laparoscopic surgery seems to provide faster convalescence compared with open surgery and hand-assisted laparoscopic surgery.

Impact of previous midline laparotomy on the outcomes of laparoscopic intestinal resections: a case-matched study.

The effectiveness of laparoscopic intestinal resection in patients with previous midline laparotomy (PML) is controversial. The aim of this study was to assess the feasibility of laparoscopic surgery and identify possible factors associated with postoperative outcomes in patients with PML. Patients with PML (at least an infraumbilical incision or longer) undergoing elective laparoscopic intestinal resection between 1997 and 2011 were case matched with patients without PML undergoing laparoscopic surgery based on age, gender, body mass index, ASA score, surgical procedure, and diagnosis. Fifty patients with PML undergoing laparoscopic intestinal resection were well matched to 50 counterparts. Conversion to open surgery (n = 8 vs. n = 4, p = 0.22), operating time (211 vs. 192 min, p = 0.22), and estimated blood loss (158 vs. 184 ml, p = 0.95) were similar between the groups. Intraabdominal adhesions (either disease related or from previous operations) were significantly more common in patients with PML (n = 24 vs. n = 11, p = 0.01). Intraoperative complications included inadvertent enterotomy and hemorrhage and were comparable between the groups (n = 1 vs. n = 0, p = 1 and n = 1 vs. n = 2, p = 1 for PML vs. no PML, respectively). One patient without PML died postoperatively from aspiration pneumonia. Overall morbidity (n = 26 vs. n = 10, p = 0.001) and particularly postoperative ileus (n = 10 vs. n = 3, p = 0.04) were significantly increased in the PML group when compared to laparoscopy without PML, unlike the respective differences in postoperative return of bowel function (4 vs. 3 days, p = 0.15), reoperations (n = 5 vs. n = 3, p = 0.72), length of hospital stay (9 vs. 6 days, p = 0.09), and readmissions (n = 5 vs. n = 4, p = 0.73). Intestinal resections in patients with PML can be frequently completed laparoscopically but are associated with worse postoperative outcomes when compared to laparoscopy on a virgin abdomen.

Single-port laparoscopic colorectal resections in obese patients are as safe and effective as conventional laparoscopy.

BACKGROUND: Obese patients pose additional operative technical difficulties, and it is unclear if the outcomes of single-port colorectal surgery are equivalent to those of conventional laparoscopy in such patients. The aim of this study was to compare perioperative variables and short-term outcomes of single-port versus conventional laparoscopy in obese patients undergoing colorectal surgery. PATIENTS AND METHODS: Obese patients (BMI ≥ 30 kg/m(2)) undergoing single-port laparoscopic colorectal resections between March 2009 and September 2012 were case matched 1:1 with obese counterparts undergoing conventional (multi-port) laparoscopic surgery based on diagnosis and operation type. RESULTS: Thirty-seven patients who underwent single-port surgery were matched with 37 conventional laparoscopic counterparts. Male gender predominated in the single-port group (26 vs 15, p = 0.02). The number of patients with a history of previous abdominal operations (17 vs 13, p = 0.48) and ASA score (3 vs 2, p = 0.6) were similar between the groups. No differences were observed with respect to conversion rate (2 vs 5, p = 0.43), operative time (146 vs 150 min, p = 0.48), estimated blood loss (159 vs 183 ml, p = 0.99), time to first flatus (3 vs 3 days, p = 0.91), time to first bowel movement (3 vs 4 days, p = 0.62), length of hospital stay (7 vs 6 days, p = 0.37), or reoperation (2 vs 1, p > 0.99), and readmission rates (2 vs 2, p > 0.99). There were no deaths. CONCLUSION: For obese patients undergoing colorectal resections, single-port laparoscopy appears to be as safe and effective as conventional laparoscopy.

Single-port laparoscopic fecal diversion: more than cosmetic benefits?

Single-port laparoscopic surgery is usually performed on patients with minor comorbidities. The aim of the study was to evaluate feasibility and efficacy of single-port fecal diversion in patients who had previous abdominal operations or comorbidities. Between October 2010 and March 2012, 14 patients with a median age of 57 years were diverted. The reasons for diversion were perianal infection/abscess (n=5), anal incontinence (n=3), radiation proctitis (n=2), colovesical fistula causing sepsis (n=1), outlet obstruction of ileal S pouch (n=1), perforation during pouchoscopy (n=1), and peritoneal carcinomatosis with enterocutaneus fistula (n=1). Median estimated blood loss was 20 mL, operative time was 52 minutes, and length of hospital stay was 4 days. Two patients had ileus postoperatively. One patient had a parastomal hernia 4 months after diversion. Single-port laparoscopic fecal diversion is a safe and feasible operation for patients with significant comorbidities and a history of multiple abdominal operations.

Transanal endoscopic surgery using a single access port: a practical tool in the surgeon's toybox.

BACKGROUND: Large polyps and early carcinomas of the rectum may be excised with transanal endoscopic surgery (TES). Single-port techniques are emerging in the field of colorectal surgery and have been adapted to many colorectal procedures so far. In this article, we aimed to present our initial experience with TES using a single access port with its technical details. PATIENTS AND METHODS: Patients undergoing TES using a single access port between July 2010 and January 2013 were included in the study. Patient demographics, operative technique, and both operative and postoperative outcomes were evaluated and presented. RESULTS: A total of 12 patients (ten males) were included in our study. The median age was 63.5 years (50-84), median American Society of Anesthesiologists (ASA) score was 3 (2-4), and median body mass index was 28.8 kg/m(2) (17.4-55.6). Median operating time was 79 min (43-261). Histopathological diagnoses were as follows: tubulovillous adenoma (n = 6), tubular adenoma (n = 4), adenocarcinoma (n = 1), and neuroendocrine tumor (n = 1). Five patients were sent home on the day of surgery and the median postoperative hospital stay was 1 day (0-38). Median estimated blood loss was 22.5 ml (5-150). A transient urinary retention was developed in one patient postoperatively, and two patients had postoperative bleeding. The first of these patients with a long history of anticoagulant usage had rectal bleeding 13 days after surgery, which was successfully managed with medical treatment. The second patient was morbidly obese, had multiple comorbidities, and had rectal bleeding on postoperative day 7 which was managed with local epinephrine injection. He suffered unrelated cardiac death on postoperative day 38. CONCLUSIONS: TES is safe and feasible when using a single port and in the standard laparoscopic setting. The single-port technique may play a major role in the widespread utilization of TES as a treatment for large adenomas and early rectal cancers.

Impact of stress dose steroids on the outcomes of restorative proctocolectomy in patients with ulcerative colitis.

BACKGROUND: Stress dose steroids are administered during the perioperative period to prevent complications of secondary hypoadrenalism, which can occur after long-term steroid treatment. Steroids also increase postoperative morbidity. Patients with ulcerative colitis often require steroid therapy before definitive surgery and often receive perioperative steroids in a variety of doses. OBJECTIVE: The aim of this study was to evaluate the impact of stress dose steroid administration on short-term postoperative outcomes after restorative proctocolectomy in patients with ulcerative colitis. DESIGN: This was a retrospective cohort study. SETTING: The investigation took place in a high-volume, specialized colorectal surgery department. PATIENTS: Patients who had been treated with steroids for ulcerative colitis and underwent a restorative proctocolectomy from January 2009 to July 2011 were identified and categorized into 2 groups based on whether they received stress dose steroids. MAIN OUTCOME MEASURES: Both cohorts were compared for patient demographics, duration of steroid treatment before surgery, and operative and postoperative outcomes. RESULTS: Eighty-nine patients received stress dose steroids and 146 patients did not. Stress dose steroids were more frequently administered to patients who were under steroid treatment immediately before restorative proctocolectomy (37.1% versus 10.3%; p < 0.001). A sinus tachycardia developed more frequently in patients who received stress dose steroids during surgery (p = 0.03). One patient in the stress dose steroid group died on postoperative day 25 because of anastomotic leak. Although no patients in either group had an adrenal crisis during surgery, 1 patient in the stress dose steroid group was diagnosed with adrenal insufficiency postoperatively. LIMITATIONS: This study was limited by its retrospective and nonrandomized nature. CONCLUSIONS: Although administration of stress dose steroids is not related to increased postoperative complications, the steroids do not appear to affect adrenal insufficiency outcomes. Patients who were treated with steroids for ulcerative colitis should be monitored carefully in the perioperative and early postoperative periods for signs of adrenal insufficiency, regardless of the steroid regimen used.

Malfunction and failure of robotic systems during general surgical procedures.

BACKGROUND: There has been recent interest in using robots for general surgical procedures. This shift in technique raises the issue of patient safety with automated instrumentation. Although the safety of robotics has been established for urologic procedures, there are scant data on its use in general surgical procedures. The aim of this study is to analyze the incidence of robotic malfunction and its consequences for general surgical procedures. METHODS: All robotic general surgical procedures performed at a tertiary center between 2008 and 2011 were reviewed from institutional review board (IRB)-approved prospective databases. RESULTS: A total of 223 cases were done robotically, including 102 endocrine, 83 hepatopancreaticobiliary, 17 upper gastrointestinal, and 21 lower gastrointestinal colorectal procedures. There were 10 cases of robotic malfunction (4.5%). These failures were related to robotic instruments (n = 4), optical system (n = 3), robotic arms (n = 2), and robotic console (n = 1). None of these failures led to adverse patient consequences or conversion to open. Six (2.7%) cases were converted to open due to bleeding (n = 3), difficult dissection plane (n = 1), invasion of tumor to surrounding structures (n = 1), and intolerance of pneumoperitoneum due to CO(2) retention (n = 1). There was no mortality, and morbidity was 1% (n = 2). CONCLUSION: To our knowledge, this is the largest North American report to date on robotic general surgical procedures. Our results show that robotic malfunction occurs in a minority of cases, with no adverse consequences. We believe that awareness of these failures and knowing how to troubleshoot are important to maintain the efficiency of these procedures.

Reduced port versus conventional laparoscopic total proctocolectomy and ileal J pouch-anal anastomosis.

BACKGROUND: The feasibility and safety of single-incision laparoscopic total proctocolectomy (TPC) and ileal pouch anal anastomosis (IPAA) were first reported in 2010. To improve accuracy and efficiency while maintaining the cosmetic advantages of single-incision laparoscopic surgery, we have since modified the technique to include the use of a 5-mm instrument placed through the eventual drain site. The aim of this study is to compare reduced port laparoscopic (RPL) IPAA with conventional laparoscopic IPAA with respect to short-term outcomes to assess safety. METHODS: RPL cases were matched to conventional laparoscopy cases for patient age (±5 years), body mass index, gender, diagnosis, type and number of stages of surgical procedure, American Society of Anesthesiologists (ASA) classification, and year of surgery (±3 years). Groups were compared using χ(2) or Fisher exact tests for categorical and Wilcoxon rank-sum test for quantitative data. RESULTS: Twenty-four RPL patients were case-matched to an equal number of patients who underwent conventional laparoscopic IPAA. Short-term outcomes including postoperative complications, length of hospital stay, and time to first bowel movement were similar between groups. Despite similar diagnosis, previous surgery, and comorbidity, operative blood loss (p < 0.001) and operating time (p = 0.02) were lower for the RPL group. CONCLUSION: RPL IPAA can be safely performed with short-term outcomes comparable to conventional laparoscopy.

Mucosal serotonin signaling is altered in chronic constipation but not in opiate-induced constipation.

OBJECTIVES: Changes in mucosal serotonin (5-HT) signaling have been detected in a number of functional and inflammatory disorders of the gastrointestinal (GI) tract. This study was undertaken to determine whether chronic constipation (CC) is associated with disordered 5-HT signaling and to evaluate whether constipation caused by opiate use causes such changes. METHODS: Human rectal biopsy samples were obtained from healthy volunteers, individuals with idiopathic CC, and individuals taking opiate medication with or without occurrence of constipation. EC cells were identified by 5-HT immunohistochemistry. 5-HT content and release levels were determined by enzyme immunoassay, and mRNA levels for the synthetic enzyme tryptophan hydroxylase-1 (TpH-1) and serotonin-selective reuptake transporter (SERT) were assessed by quantitative real-time reverse transcription PCR. RESULTS: CC was associated with increases in TpH-1 transcript, 5-HT content, and 5-HT release under basal and stimulated conditions, whereas EC cell numbers and SERT transcript levels were not altered. No changes in these elements of 5-HT signaling were detected in opiate-induced constipation (OIC). CONCLUSIONS: These findings demonstrate that CC is associated with a pattern of altered 5-HT signaling that leads to increased 5-HT availability but does not involve a decrease in SERT expression. It is possible that increased 5-HT availability due to increased synthesis and release contributes to constipation due to receptor desensitization. Furthermore, the finding that elements of 5-HT signaling were not altered in the mucosa of individuals with OIC indicates that constipation as a condition does not lead to compensatory changes in 5-HT synthesis, release, or signal termination.

Serotonin signaling in diverticular disease.

Diverticulosis is extremely common in Western societies and is associated with complications in up to 15%of cases. Altered motility is an important feature of the pathogenesis of diverticular disease, and serotonin (5-HT) release is a primary trigger of gut motility. This study aims to determine whether colonic 5-HT signaling is altered in patients with diverticulosis or diverticulitis, and whether differences in serotonin signaling may distinguish patients with asymptomatic diverticulosis from those who develop disease specific complications. Sigmoid colon biopsies were obtained from healthy control subjects, individuals with asymptomatic diverticulosis, and those with a history of CT-proven diverticulitis within the preceding 6 months. The key elements of 5-HT signaling including content, release, and 5-HT transporter (SERT) expression were analyzed. A significant decrease in SERT transcript levels was present in the mucosa of patients with a history of diverticulitis when compared with controls, but not in those with asymptomatic diverticulosis. Mucosal 5-HT content, enterochromaffin (EC) cell numbers, and TpH-1 mRNA levels were comparable amongst the groups, as were basal and stimulated 5-HT release. Alterations in 5-HT signaling do not appear to be responsible for the development of diverticula. However, patients with a recent history of acute diverticulitis have a significant attenuation in SERT expression and function, likely secondary to previous inflammation. Our findings may explain the persistent symptoms of pain and altered motility so often observed in patients with diverticulitis long after recovery from the acute inflammatory response.

Serotonin and its role in colonic function and in gastrointestinal disorders.

Serotonin (5-HT) is most commonly thought of as a neurotransmitter in the central nervous system. However, the predominant site of serotonin synthesis, storage, and release is the enterochromaffin cells of the intestinal mucosa. Within the intestinal mucosa, serotonin released from EC cells activates neural reflexes associated with intestinal secretion, motility, and sensation. Two important receptors for serotonin that are located in the neural circuitry of the intestines are the 5-HT(3) and 5-HT(4) receptors; these are the targets of drugs designed to treat gastrointestinal disorders. 5-HT(3) receptor antagonists are used to treat nausea and emesis associated with chemotherapy and for functional disorders associated with diarrhea. 5-HT(4) receptor agonists are used as promotility agents to promote gastric emptying and to alleviate constipation. Because of the importance of serotonin in normal gut function and sensation, a number of studies have investigated potential changes in mucosal serotonin signaling in pathologic conditions. Despite the inconsistencies in the current literature, changes in serotonin signaling have now been demonstrated in inflammatory bowel disease, irritable bowel syndrome, postinfectious irritable bowel syndrome, and idiopathic constipation. Emerging evidence has led to many contradictory theories regarding serotonin signaling and its roles in the pathology of gut disorders. This review summarizes the current medications affecting serotonin signaling and provides an overview of our current knowledge of the changes in serotonin that occur in pathologic conditions.