This study evaluates factors associated with a pathologic complete response (pCR) after neoadjuvant chemoradiation for rectal cancer.
Approximately 20% of rectal cancer patients undergoing ...neoadjuvant chemoradiation achieve pCR, which has been associated with decreased local recurrence and improved recurrence-free survival. Means of predicting pCR remain incompletely defined.
A total of 306 consecutive patients with stage II or stage III rectal cancer who underwent neoadjuvant chemoradiation then surgery between 1997 and 2007 were identified from a single-institution. Sixty-four patients with concurrent inflammatory bowel disease, hereditary colorectal cancer, other malignancy, urgent surgery, incomplete chemoradiation, or insufficient data were excluded. All patients received neoadjuvant 5-FU-based chemotherapy and external beam radiation. Histologic response was categorized as pCR or not-pCR, which defined the 2 study cohorts. Variables were analyzed by univariate and multivariate analysis with pCR as the dependent variable. Fisher exact test, chi2, Wilcoxon rank-sum, and logistic regression were used for analysis. P < 0.05 was considered statistically significant.
Of the total patients, 242 were studied, including 58 (24%) that achieved pCR. The 2 groups were statistically similar in terms of age, gender, body mass index, tumor differentiation, radiation dose, and pretreatment stage. On multivariate analysis, an interval ≥ 8 weeks between treatment completion and surgical resection was significantly associated with a higher rate of pCR, which correlated with decreased local recurrence and improved overall survival.
Despite traditional beliefs that certain patient and tumor factors influence pCR, an extended interval between completion of neoadjuvant therapy and surgery was the single most important determinant in achieving a pCR.
This study was designed to review safety and efficacy of strictureplasty for Crohn's disease.
A literature search was performed to identify studies published between 1975 and 2005 that reported the ...outcome of strictureplasty. Systematic review was performed on the following subjects separately: 1) overall experience of strictureplasty; 2) postoperative complications; 3) postoperative recurrence and site of recurrence; 4) factors affecting postoperative complications and recurrence; 5) short-bowel syndrome; and 6) cancer risk. Meta-analysis of recurrence rate after strictureplasty was performed by using random-effect model and meta-regressive techniques.
A total of 1,112 patients who underwent 3,259 strictureplasties (Heineke-Mikulicz, 81 percent; Finney, 10 percent; side-to-side isoperistaltic, 5 percent) were identified. The sites of strictureplasty were jejunum and/or ileum (94 percent), previous anastomosis (4 percent), duodenum (1 percent), and colon (1 percent). After jejunoileal strictureplasty, including ileocolonic strictureplasty, septic complications (leak/fistula/abscess) occurred in 4 percent of patients. Overall surgical recurrence was 23 percent (95 percent confidence interval, 17-30 percent). Using meta-regressive analysis, the five-year recurrence rate after strictureplasty was 28 percent. In 90 percent of patients, recurrence occurred at nonstrictureplasty sites, and the site-specific recurrence rate was 3 percent. Two patients developed adenocarcinoma at the site of previous jejunoileal strictureplasty. The experience of duodenal or colonic strictureplasty was limited.
Strictureplasty is a safe and effective procedure for jejunoileal Crohn's disease, including ileocolonic recurrence, and it has the advantage of protecting against further small bowel loss. However, the place for strictureplasty is less well defined in duodenal and colonic diseases.
Background
The aim of this study was to evaluate the clinical implications of pathologic complete response (pCR) (i.e., T0N0M0) after neoadjuvant chemoradiation and radical surgery in patients with ...locally advanced rectal cancer.
Materials and Methods
A single-center, prospectively maintained colorectal cancer database was queried for patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI undergoing long-course neoadjuvant chemoradiation followed by proctectomy with curative intent between 1997 and 2007. Patients were stratified into pCR and no-pCR groups and compared with respect to demographics, tumor and treatment characteristics, and oncologic outcomes. Outcomes evaluated were 5-year overall survival, disease-free survival, disease-specific mortality, local recurrence, and distant recurrence.
Results
The query returned 238 patients (73% male), with a median age of 57 years and median follow-up of 54 months. Of these, 58 patients achieved pCR. Patients with pCR vs no-pCR were statistically comparable with respect to demographics, chemoradiation regimens, tumor distance from anal verge, clinical stage, surgical procedures performed, and follow-up time. No patient with pCR had local recurrence. Overall survival and distant recurrence were also significantly improved for patients achieving pCR.
Conclusions
Achievement of pCR after neoadjuvant chemoradiation is associated with greatly improved cancer outcomes in locally advanced rectal cancer. Future studies should evaluate the relationship between increases in pCR rates and improvements in cancer outcomes in this population.
Background The purpose of this study was to analyze long-term recurrence rates and complications in patients previously enrolled in a prospective randomized trial comparing laparoscopic (LC) and open ...ileocolectomy (OC) for ileocolic Crohn's disease (CD). Methods Follow-up data were available on 56 of 60 patients. Demographic data, recurrence rates, need for additional surgery related to primary procedure, and medication use were recorded. Results Mean follow-up for 56 patients (27 LC vs 29 OC) was 10.5 years and comparable between LC and OC (10.0 vs 11.0, respectively; P = .64). One patient died 8 years after OC of causes unrelated to CD. Eight patients for each group underwent initial reoperative (26% LC vs 28% OC; P = .89). One patient underwent incisional hernia repair after LC (4%) versus 4 patients (14%) after OC ( P = .61). Two patients in the LC group underwent adhesiolysis versus none after OC ( P = .23). Incidences of anorectal disease, anorectal surgery, endoscopic or radiologic recurrence, and medication use were also similar between LC and OC. OC patients requiring operation during follow-up were significantly more likely than LC to require multiple operations ( P = .006). Conclusions Long-term data from this prospective randomized trial confirm that LC is at least comparable to OC in the treatment of ileocolic CD.
Postoperative ileus (POI) after colorectal surgery is associated with prolonged hospital stay and increased costs. The aim of this study is to investigate pre-, intra-, and postoperative risk factors ...associated with the development of POI in patients undergoing laparoscopic partial colectomy.
Patients operated between 2004 and 2008 were retrospectively identified from a prospectively maintained database, and clinical, metabolic, and pharmacologic data were obtained. Postoperative ileus was defined as the absence of bowel function for 5 or more days or the need for reinsertion of a nasogastric tube after starting oral diet in the absence of mechanical obstruction. Associations between likelihood of POI and study variables were assessed univariably by using χ tests, Fisher exact tests, and logistic regression models. A scoring system for prediction of POI was constructed by using a multivariable logistic regression model based on forward stepwise selection of preoperative factors.
A total of 413 patients (mean age, 58 years; 53.5% women) were included, and 42 (10.2%) of them developed POI. Preoperative albumin, postoperative deep-vein thrombosis, and electrolyte levels were associated with POI. Age, previous abdominal surgery, and chronic preoperative use of narcotics were independently correlated with POI on multivariate analysis, which allowed the creation of a predictive score. Patients with a score of 2 or higher had an 18.3% risk of POI (P < 0.001).
Postoperative ileus after laparoscopic partial colectomy is associated with specific preoperative and postoperative factors. The likelihood of POI can be predicted by using a preoperative scoring system. Addressing the postoperative factors may be expected to reduce the incidence of this common complication in high-risk patients.
To provide a multidimensional analysis of the learning curve in major laparoscopic colonic and rectal surgery and compare outcomes between right-sided versus left-sided resections.
The laparoscopic ...learning curve is known to vary between surgeons, may be influenced by the patient selection and operative complexity, and requires appropriate case-mix adjustment.
This is a descriptive single-center study using routinely collected clinical data from 900 patients undergoing laparoscopic surgery between November 1991 and April 2003. Outcome measures included operation time, conversion rate (CR), and readmission and postoperative complication rates. Multifactorial logistic regression analysis was used to identify patient-, surgeon-, and procedure-related factors associated with conversion of laparoscopic to open surgery. A risk-adjusted Cumulative Sum (CUSUM) model was used for evaluating the learning curve for right and left-sided resections.
The conversion rate for right-sided colonic resections was 8.1% (n = 457) compared with 15.3% for left-sided colorectal resections (n = 443). Independent predictors of conversion of laparoscopic to open surgery were the body mass index (BMI) (odds ratio OR = 1.07 per unit increase), ASA grade (OR = 1.63 per unit increase), type of resection (left colorectal versus right colonic procedures, OR = 1.5), presence of intra-abdominal abscess (OR = 5.0) or enteric fistula (OR = 4.6), and surgeon's experience (OR 0.9 per 10 additional cases performed). Having adjusted for case-mix, the CUSUM analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for left-sided resections. Median operative time declined with operative experience (P<0.001). Readmission rates and postoperative complications remained unchanged throughout the series and were not dependent on operative experience.
Conversion rates for laparoscopic colectomy are dependent on a multitude of factors that require appropriate adjustment including the learning curve (operative experience) for individual surgeons. The laparoscopic model described can be used as the basis for performance monitoring between or within institutions.
Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy ...with ileal pouch–anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.
Background The aim of this study was to compare outcomes after primary hand-sewn versus stapled ileal pouch-anal anastomosis (IPAA). Methods Patients undergoing a primary IPAA (1983–2007) were ...identified from a prospective pelvic pouch database. Differences between group A (hand-sewn) and group B (stapled) for pre-operative and peri-operative factors, complications, functional outcomes, and quality of life (QOL) were investigated. Results Of 3,382 patients with a primary IPAA, 3,109 were included. Median follow-up was 7.1 years (0.1–24). Mean age was 37.9 ± 13.2 years. Overall, 1,741 patients (56%) were male. Group A ( n = 474) and group B ( n = 2635) had similar age ( P = .28), sex ( P = .8), albumin level ( P = .74), prior colectomy ( P = .98), and use of steroids ( P = .1). Group A had a greater use of ileostomy ( P = .001) and a longer duration of stay ( P < .001). Group B had a greater body mass index ( P < .001) and J-pouch ( P ≤ .001). Wound infection ( P = .42) and pouchitis ( P = .59) were similar. Anastomotic stricture ( P = .002), septic complications ( P = .019), bowel obstruction ( P = .027), and pouch failure ( P < .001) were greater in group A. At most recent follow-up, bowel frequency ( P = .74) and rate of urgency were similar ( P = .71). A greater proportion of patients in group A described incontinence ( P < .001), seepage ( P < .001), pad usage ( P < .001), dietary ( P < .001), social ( P < .001), and work restrictions ( P = .025). The Cleveland Global QOL score ( P = .018) was greater in group B. Conclusion Patients undergoing a stapled IPAA had better outcomes and QOL than those undergoing a hand-sewn IPAA.
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on May 18, ...2003, and by the AGA Governing Board on July 25, 2003.
To evaluate whether resident participation in operations influences postoperative outcomes.
: Identification of potential differences in outcome associated with resident participation in operations ...may facilitate planning from educational and health resource perspectives.
From the National Surgical Quality Improvement Program database (2005-2007), postoperative outcomes were compared for patients with and without resident participation (RES vs no-RES). Groups were matched in a 2:1 ratio, based on age, sex, specialty, surgical procedure, morbidity probability, and important comorbidities and risk factors.
RES (40,474; 66.7%) and no-RES (20,237; 33.3%) groups were comparable for matched characteristics. Mortality was similar (0.18% vs 0.20%, P = 0.55). Thirty-day complications classified as "mild" (4.4% vs 3.5%, P < 0.001) and "surgical" (7% vs 6.2%, P < 0.001) were higher in RES group. Individual complications were largely similar, except superficial surgical site infection (3.0% vs 2.2%, P < 0.001). Operative time was longer in the RES group mean (SD) 122 (80) vs 97 (67) minutes, P < 0.001. Overall complications were lower for postgraduate year 1-2 residents than for other years. These differences persisted on multivariate analysis adjusting for confounders.
Resident involvement in surgical procedures is safe. The small overall increase in mild surgical complications is mostly caused by superficial wound infections. Reasons for this are likely multifactorial but may be related to prolonged operative time.
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