Recurrence pattern and outcomes in T4 colon cancer: A single institution analysis.

BACKGROUND AND OBJECTIVES: Patients with T4 colon adenocarcinoma have an increased risk of locoregional and distant recurrence. This study defines the metastatic pattern, predictors of recurrence, and efficacy of adjuvant treatment in T4 colon cancer. METHODS: A retrospective review was performed of patients with T4 colon adenocarcinoma from May 2005 to November 2015 at a tertiary care hospital. Baseline factors, follow-up, recurrence, and survival were collected and analyzed. RESULTS: Locoregional recurrence (LR) rates for N0, N1, and N2 were 21/85 (24.7%), 14/50 (28%), and 21/46 (45.7%), respectively (P = .014). Multivariate analysis for distant recurrence was significant for positive nodes (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.1-9.9). Multivariate analysis for LR was significant for the following variables: perforation (HR, 2.7; 95% CI, 1.2-6.2), lymphovascular invasion (HR, 2.7; 95% CI, 1.1-6.7), positive nodes (HR, 2.8; 95% CI, 1.2-6.9), and positive margins (HR, 5.0; 95% CI, 2.1-12.1). Multivariate analysis for overall survival was significant for: signet ring histology (HR, 2.5; 95% CI, 1.2-5.8), positive nodes (HR, 2.3; 95% CI, 1.2-4.4), and positive margin (HR, 2.8; 95% CI, 1.4-5.8). CONCLUSION: T4 colon adenocarcinoma has a high risk of LR and mortality. Clinical trials utilizing the aforementioned high-risk features may increase the ability to demonstrate beneficial intervention.

A medial to lateral approach offers a superior lymph node harvest for laparoscopic right colectomy.

PURPOSE: Studies have shown improved survival with increasing amounts of harvested lymph nodes. The purpose of this study was to evaluate two laparoscopic techniques to right colectomy, laparoscopic medial to lateral (MtL) approach and laparoscopic lateral to medial (LtM) approach, in patients undergoing a right colectomy for either endoscopically unresectable polyps or carcinoma and determine which technique offers the optimal lymph node harvest. METHODS: Patients that underwent a laparoscopic right colectomy over a 5-year period were identified. Charts were reviewed with regards to demographics, surgical approach, length of stay (LOS) and number of lymph nodes harvested. Variables were statistically analyzed and outcomes compared between the two groups. A p value of less than 0.05 was considered statistically significant. RESULTS: Two hundred thirty-three patients underwent a laparoscopic right colectomy over a 5-year period for endoscopically unresectable polyps or carcinoma. Seventy-nine patients underwent a MtL approach and 154 patients underwent a LtM approach. When comparing the two groups, there were more females in the MtL group relative to the LtM group (78% vs 66%; p = 0.0015). When the outcome of number of lymph nodes harvested was examined, there was a significantly larger number of nodes harvested in the MtL (median = 24) approach compared to the LtM approach (median = 19; p = 0.0002). LOS was similar between the MtL and LtM group (median 4 days for both). CONCLUSIONS: The laparoscopic MtL approach to right colectomy yields a larger lymph node harvest compared to the laparoscopic LtM approach.

Does sedation type affect colonoscopy perforation rates?

BACKGROUND: Sedation with propofol is gaining popularity. It is unclear whether sedation with propofol is associated with colonoscopic perforation. OBJECTIVE: The purpose of this study was to compare perforation rates during colonoscopy using sedation with or without propofol. DESIGN: This was a retrospective case series study. SETTINGS: Data from a tertiary center were analyzed. Demographics, method of sedation, and type of endoscopic procedure performed were collected. PATIENTS: Patients who underwent a colonoscopy from January 2003 to October 2012 were analyzed. MAIN OUTCOME MEASURES: Perforation rate expressed per 10,000 colonoscopies was measured. RESULTS: A total of 118,004 colonoscopies were performed during the study period, with 48 perforations (0.041% or 4.1 per 10,000). Overall, the use of propofol was associated with a 2.5 times increased rate of perforation (6.9 vs 2.7 per 10,000; p = 0.0015). Similarly, in patients undergoing therapeutic colonoscopies, there was a 3.4-times increased risk of perforation associated with the use of propofol (8.7 vs 2.6 per 10,000; p = 0.0016). However, in patients undergoing diagnostic colonoscopies, there was no significantly increased risk of perforation with the use of propofol (4.2 vs 2.9 per 10,000; p = 0.64). In univariate and multivariate analyses, there were no differential perforation risks on the basis of sex, but each decade increase in age was associated with an increased risk of perforation. In those patients having a therapeutic colonoscopy, age (per decade) and propofol use were independently and significantly associated with an increased perforation risk, with adjusted ORs of 1.32 (p = 0.04) and 3.38 (p = 0.001). LIMITATIONS: This was a retrospective study with the potential for selection bias. CONCLUSIONS: This study shows that propofol administration is associated with an increased risk of colonoscopic perforation among patients undergoing a therapeutic colonoscopy; however, this association was not evident in patients undergoing a diagnostic colonoscopy. Further studies, such as a prospective, randomized clinical trial, should be done to further evaluate this association.

Perioperative Lidocaine Infusion Reduces Opioid Use in Enhanced Recovery After Surgery Patients Undergoing Laparoscopic Colectomy.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs have become a mainstay of modern surgical care, and efforts to decrease postoperative opioid consumption have been increasingly employed. A previous study from our institution demonstrated that ERAS protocols decreased opioid use in the first 48 hours after surgery by 61%. In the present study, a lidocaine infusion was added for postoperative pain control. The aim was to analyze the differences in opioid requirements with and without this infusion in the first 48 hours after laparoscopic colectomy in ERAS patients. METHODS: Retrospective review of patients was conducted at an academically affiliated tertiary care hospital. The population included patients undergoing elective laparoscopic colon surgery enrolled in the ERAS program with the implementation of a lidocaine drip from June 2019 to October 2019, and compared to a previous patient cohort of ERAS patients evaluated without the lidocaine drip from September 2015 to May 2018. RESULTS: The primary endpoint was postoperative opioid use in the first 48 hours based on IV morphine milligram equivalents (MME). Secondary measures included type of surgery, age, BMI, prior abdominal surgery, and prior opioid use. Median MMEs were 6.0 in the lidocaine infusion group and 12.5 in the group without lidocaine, representing a 52% reduction (p < 0.001). DISCUSSION: This study demonstrates a significant reduction in post-op opioid use in ERAS patients who receive a lidocaine infusion after laparoscopic colectomy. Further studies should focus on measures to limit the treatment side effects in order to maximize the opioid-sparing benefits of this intervention.

Multidisciplinary management of colorectal cancer enhances access to multimodal therapy and compliance with National Comprehensive Cancer Network (NCCN) guidelines.

PURPOSE: Multidisciplinary teams have become increasingly desirable for managing complex disease but little objective data exist to support this approach. The aim of our study was to determine the impact of a multidisciplinary clinic on the management of colorectal cancer. METHODS: Data were prospectively collected on all patients with newly diagnosed colorectal cancer referred to the multidisciplinary clinic at our institution in 2009 and compared to a control group of all patients managed outside the clinic from 2008 to 2009. Comprehensiveness of preoperative evaluation was determined by frequency of abdominal and chest CT, CEA testing, and transrectal ultrasound. Access to multimodal care was measured by frequency of oncology consultation and treatment, advanced pathology testing, genetics counseling, and trial enrollment. RESULTS: Two hundred eighty-eight patients met inclusion criteria; 88 patients were referred to the clinic (40 preoperative, 48 postoperative) and 200 patients were managed outside. Complete preoperative evaluation was accomplished three times more frequently in clinic patients (85 vs. 23 %, p < 0.0001) with significant improvements in all parameters. Enhanced access to multimodal therapy was demonstrated in clinic patients by increased frequency of oncology consultation (98.9 vs. 61.5 %, p < 0.0001) and treatment (62.5 vs. 41.5 %, p = 0.02), advanced pathology testing (29.6 vs. 10.6 %, p = 0.0001), and genetics counseling (6.8 vs. 1.6 %, p = 0.28). Clinic patients also received significantly higher rates of neoadjuvant therapy for stage II or greater rectal cancer (82.6 vs. 30.9 %, p = 0.0001). CONCLUSIONS: Multidisciplinary clinic management of colorectal cancer is associated with a significantly more complete preoperative evaluation as well as improved access to multimodal therapy.

Can the American College of Surgeons National Surgical Quality Improvement Program Risk Calculator Predict Outcomes for Urgent Colectomies?

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Risk Calculator (RC) predicts postoperative outcomes using 19 risk factors, including operative acuity. Acuity is defined by the calculator as emergent or elective only. The objective of this study is to evaluate the RC's accuracy in urgent (nonelective/nonemergent) cases. METHODS: This is a retrospective review of the NSQIP data for patients who underwent urgent colectomies at a single tertiary care center over a 4-year period. Each urgent case was entered into the RC as both elective and emergent, and predicted outcomes were compared to actual postoperative outcomes. Receiver operating characteristic (ROC) curves were used when sufficient statistical power was present and the area under the curve (AUC) was calculated. RESULTS: A total of 301 urgent colectomy patients were evaluated, representing 19% of all colectomies performed at our institution during the study period. Of the 15 possible postoperative outcomes, the RC showed high predictive value only for mortality (AUC elective .8467; emergent .8451) and discharge to a nursing/rehabilitation facility (AUC elective .8089; emergent .8105). The RC showed no predictive value for 6 outcomes and the remainder lacked statistical power to draw conclusions. DISCUSSION: While the calculator predicted mortality and discharge to a nursing/rehabilitation facility, it did not accurately predict complications for urgent colectomies. Future versions of the calculator should focus on improving the predictive value by including urgent cases as a separate category.

Evaluating the age distribution of patients with colorectal cancer: are the United States Preventative Services Task Force guidelines for colorectal cancer screening appropriate?

PURPOSE: Evaluate the appropriateness of the 2008 United States Preventative Services Task Force screening recommendations for colorectal cancer. METHODS: Ages at diagnosis data were collected on patients with colorectal cancer from the William Beaumont Tumor Registry. The database identified 6,925 patients treated for colorectal cancer between January 1973 and December 2007. Patients were divided into 3 age groups at diagnosis categories (younger than 50 years old, those 50 to 75 years old, and those older than 75 years old) to evaluate whether there were changes in the age distribution, pathologic stage, or tumor location during the 35-year period. RESULTS: The percent of patients with colorectal cancer older than age 75 years increased from 29% to 40% (P < .0001). The combined percentage of patients younger than age 50 years and older than age 75 years has increased from 36% (1973-1978) to 49% (2003-2007). The combined percentages of stage III and IV disease in patients younger than 50 years and older than 75 years were 51% and 34%, respectively (P < .0001). Rectal or left-sided lesions occurred in 68%, 64%, and 50% of patients younger than 50 years old, those 50 to 75 years old, and those older than 75 years old, respectively (P < .0001). Right-sided lesions occurred in 22%, 25%, and 37% of those younger than 50 years old, those 50 to 75 years old, and those older than 75 years old, respectively (P < .0001). CONCLUSIONS: There has been a significant increase in the percentage of colorectal cancer patients older than age 75 years. Failing to screen patients younger than 50 years and older than the age of 75 years would miss 49% of patients treated at our institution from 2003 to 2007.

Genomic variation as a marker of response to neoadjuvant therapy in locally advanced rectal cancer.

There is variation in the responsiveness of locally advanced rectal cancer to neoadjuvant chemoradiation, from complete response to total resistance. This study compared genetic variation in rectal cancer patients who had a complete response to chemoradiation versus poor response, using tumor tissue samples sequenced with genomics analysis software. Rectal cancer patients treated with chemoradiation and proctectomy June 2006-March 2017 were grouped based on response to chemoradiation: those with no residual tumor after surgery (CR, complete responders, AJCC-CPR tumor grade 0, n = 8), and those with poor response (PR, AJCC-CPR tumor grade two or three on surgical resection, n = 8). We identified 195 variants in 83 genes in tissue specimens implicated in colorectal cancer biopathways. PR patients showed mutations in four genes not mutated in complete responders: KDM6A, ABL1, DAXX-ZBTB22, and KRAS. Ten genes were mutated only in the CR group, including ARID1A, PMS2, JAK1, CREBBP, MTOR, RB1, PRKAR1A, FBXW7, ATM C11orf65, and KMT2D, with specific discriminating variants noted in DMNT3A, KDM6A, MTOR, APC, and TP53. Although conclusions may be limited by small sample size in this pilot study, we identified multiple genetic variations in tumor DNA from rectal cancer patients who are poor responders to neoadjuvant chemoradiation, compared to complete responders.

The Colectomy Improvement Project: Do Evidence-Based Guidelines Improve Institutional Colectomy Outcomes?

This study evaluates whether increased adherence to eight specific practice parameters leads to improved outcomes in patients undergoing elective colorectal resections. In addition, we analyzed whether physicians with better compliance achieved better patient outcomes. Compliance to practice parameters and subsequent outcomes were compared between two groups relative to an educational intervention promoting the eight best practice guidelines selected. A total of 485 patients were identified over a 4-year period and were separated into a pre- (n = 273) and posteducation (n = 212) group. After the educational intervention, there was increased compliance in five of the eight practice parameters (P < 0.05). When outcomes where examined, the readmission rate (2.4% vs 8.4%; P = 0.005) and the incidence of deep surgical infections (0% vs 1.8%; P = 0.01) were significantly decreased when comparing the posteducational group to that of the group before intervention. A lower rate of anastomotic leaks were identified in the posteducation group, but this did not reach significance (1.9% vs 5.1%; P = .09). When analyzed individually, the most compliant physicians achieved better patient outcomes than their peers. Education of the operative team improved adherence to practice parameters and this may have contributed to improving patient outcomes.

Safety and efficacy of superselective angioembolization in control of lower gastrointestinal hemorrhage.

BACKGROUND: We evaluated the safety and efficacy of angioembolization to control lower gastrointestinal hemorrhage. METHODS: Retrospective chart review of patients undergoing angiography for lower gastrointestinal hemorrhage from January 2000 to December 2002. RESULTS: Seventy-seven patients with lower gastrointestinal hemorrhage underwent mesenteric angiography. Angioembolization was performed in 11 patients. Sixty-six patients were not embolized; 47 of these were treated medically and 19 surgically. Mortality rate was not significantly different in patients treated surgically (3 of 19, 16%) versus those managed medically (6 of 47, 13%; P = 0.746). Of the 11 patients who were embolized, 10 had immediate cessation of hemorrhage, 7 had gastrointestinal ischemia, and 6 died (55%). Overall mortality in non-embolized patients was 9 of 66 (14%; P = 0.002 versus mortality in embolized patients). CONCLUSIONS: Angioembolization, though effective at controlling hemorrhage, is associated with ischemic complications and a high mortality rate. Our data support surgical or medical management for lower gastrointestinal hemorrhage.

Retrorectal teratoma: a rare cause of pain in the tailbone.

Retrorectal tumors are extremely rare and heterogeneous, requiring complete surgical excision for definitive diagnosis and optimal outcome. We describe a patient presenting with chronic "tailbone pain" who was found to have a benign cystic teratoma in the presacral space. She underwent en bloc resection and recovered well. Radiographic and pathologic images from this unique case are depicted and clinical features discussed.

Endoprosthetic management of refractory ileocolonic anastomotic strictures after resection for Crohn's disease: report of nine-year follow-up and review of the literature.

BACKGROUND: The role of endoluminal stenting in benign obstruction, especially for Crohn's disease (CD), is controversial, with limited data and widely disparate outcomes. The purpose of this study was to determine the long-term efficacy and safety of this technology in the treatment of fibrostenotic CD and to review the existing literature on this topic. METHODS: We undertook a retrospective review of all patients undergoing endoluminal stenting for CD strictures at our institution from 2001 to 2010. Outcome measures included technical success, clinical improvement, duration of stent and luminal patency, and need for re-intervention. RESULTS: Five patients underwent this procedure with a 100% rate of technical and an 80% rate of clinical success. Mean follow-up was 28 months (range 3 weeks to 109 months) and mean long-term luminal patency was 34.8 months (range 4.5-109 months). There was one complication involving reobstruction which required surgical intervention and no mortalities. CONCLUSIONS: Endoluminal stenting of CD strictures is a safe and effective alternative to surgery which can provide lasting benefit in select patients. Further studies are necessary to clarify the full impact of this technology on long-term management of this complex disease.

Risk factors for anastomotic leak and mortality in diabetic patients undergoing colectomy: analysis from a statewide surgical quality collaborative.

OBJECTIVES: To determine the risk factors in diabetic patients that are associated with increased postcolectomy mortality and anastomotic leak. DESIGN: A prospectively acquired statewide database of patients who underwent colectomy was reviewed. Primary risk factors were diabetes mellitus, hyperglycemia (glucose level ≥ 140 mg/dL), steroid use, and emergency surgery. Categorical analysis, univariate logistic regression, and multivariate regression were used to evaluate the effects of these risk factors on outcomes. SETTING: Participating hospitals within the Michigan Surgical Quality Collaborative. PATIENTS: Database review of patients from hospitals within the Michigan Surgical Quality Collaborative. MAIN OUTCOME MEASURES: Anastomotic leak and 30- day mortality rate. RESULTS: Of 5123 patients, 153 (3.0%) had leaks and 153 (3.0%) died. Preoperative hyperglycemia occurred in 15.6% of patients, only 54% of whom were known to have diabetes. Multivariate analysis showed that the risk of leak for patients with and without diabetes increased only by preoperative steroid use (P<.05). Mortality among diabetic patients was associated with emergency surgery (P<.01) and anastomotic leak (P<.05); it was not associated with hyperglycemia. Mortality among nondiabetic patients was associated with hyperglycemia (P<.005). The presence of an anastomotic leak was associated with increased mortality among diabetic patients (26.3% vs 4.5%; P<.001) compared with nondiabetic patients (6.0% vs 2.5%; P<.05). CONCLUSIONS: The presence of diabetes did not have an effect on the presence of an anastomotic leak, but diabetic patients who had a leak had more than a 4-fold higher mortality compared with nondiabetic patients. Preoperative steroid use led to increased rates of anastomotic leak in diabetic patients. Mortality was associated with hyperglycemia for nondiabetic patients only. Improved screening may identify high-risk patients who would benefit from perioperative intervention.

Implementing a multidisciplinary open-access clinic at a private practice-based community hospital.

With the acquisition of emerging technologies in the treatment of primary and metastatic hepatic malignancy by interventional radiology, a multidisciplinary tumor board was created by the authors to improve treatment planning for these diseases.

A randomized, prospective, double-blind, placebo-controlled trial of the effect of a calcium channel blocker ointment on pain after hemorrhoidectomy.

PURPOSE: Spasm of the internal sphincter plays a role in hemorrhoidal disease and may be a source of anal pain after hemorrhoid surgery. We have evaluated the effects of topical diltiazem, a calcium channel blocker, in reducing pain after hemorrhoidectomy. METHODS: After hemorrhoidectomy, 18 patients were randomly assigned to receive 2 percent diltiazem ointment (n = 9) or a placebo ointment (n = 9). Ointments were applied to the perianal region three times daily for seven days. Patients were prescribed hydrocodone bitartrate (Vicodin) to take as needed. The type and number of prescribed or nonprescribed medications taken during the postoperative period were recorded. Patients maintained a log to measure postoperative pain daily and perceived benefit of the ointment, using a Visual Analog Scale ranging from 0 to 10. Any postoperative morbidity noted during the follow-up period was recorded. RESULTS: Patients using the diltiazem ointment had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week. Postoperative pain scores in the placebo group averaged 8.8 +/- 1.2 early and diminished to 5.2 +/- 1.7 at the end of one week, compared to the diltiazem group of 5.2 +/- 2.4 early and 2.3 +/- 1.2 at the end of one week (P < 0.001, both time periods). Perceived benefit in the placebo group averaged 2.7 +/- 1.2 vs. 5.6 +/- 1.4 in the diltiazem group (P < 0.001). Total and daily narcotic use was higher in the placebo group, but this was not statistically significant (P = 0.13). No differences in the frequency of use of nonsteroidal anti-inflammatory drugs and acetaminophen were seen between the two groups, and there were no differences in morbidity between the two groups. CONCLUSIONS: Perianal application of 2 percent diltiazem ointment after hemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial, with no increase in associated morbidity. Patients using a placebo ointment tend to take more prescription narcotics for pain relief postoperatively, with a similar usage of nonsteroidal anti-inflammatory drugs and acetaminophen, although differences were not significant.

Minimally invasive, endoscopically assisted colostomy can be performed without general anesthesia or laparotomy.

PURPOSE: Fecal diversion is frequently required in critically ill patients who may not be able to tolerate a laparotomy. Laparoscopic-assisted and trephine colostomies are alternative methods for colostomy without laparotomy, but require general anesthetic. The objective of this study was to evaluate the possibility of performing fecal diversion with the assistance of a colonoscope and without the additional morbidity of abdominal exploration or general anesthesia. METHODS: Patients were diverted using a colonoscope to identify a site of the sigmoid colon that could easily be approximated to the anterior abdominal wall as confirmed by transillumination of the abdominal wall. A small skin disc was then removed at this location and a loop colostomy was made. The colonoscope was also used as a guide to identify the proximal and distal limbs of the loop colostomy. Four patients were considered to be critically ill and local or regional anesthetic with sedation was used in these patients. RESULTS: A total of 15 patients were reviewed during the past five years. All 15 patients were successfully diverted using minimally invasive techniques with the aid of the colonoscope. Four of these patients were diverted using local or regional anesthetic without complication, thus avoiding the morbidity associated with a general anesthetic in critically ill patients. CONCLUSION: No complications related to this technique were noted in this five-year review. Endoscopically assisted colostomy is an acceptable method for fecal diversion without the need for laparotomy and can be accomplished using a local or regional anesthetic with sedation.