Hussan, Hisham

The determination of an optimal treatment plan for an individual patient with rectal cancer is a complex process. In addition to decisions relating to the intent of rectal cancer surgery (ie, curative or palliative), consideration must also be given to the likely functional results of treatment, including the probability of maintaining or restoring normal bowel function/anal continence and preserving genitourinary functions. Particularly for patients with distal rectal cancer, finding a balance between curative-intent therapy while having minimal impact on quality of life can be challenging. Furthermore, the risk of pelvic recurrence is higher in patients with rectal cancer compared with those with colon cancer, and locally recurrent rectal cancer is associated with a poor prognosis. Careful patient selection and the use of sequenced multimodality therapy following a multidisciplinary approach is recommended. These NCCN Guidelines Insights detail recent updates to the NCCN Guidelines for Rectal Cancer, including the addition of endoscopic submucosal dissection as an option for early-stage rectal cancer, updates to the total neoadjuvant therapy approach based on the results of recent clinical trials, and the addition of a “watch-and-wait” nonoperative management approach for clinical complete responders to neoadjuvant therapy.

Colorectal cancer (CRC) is the fourth most frequently diagnosed cancer and the second leading cause of cancer death in the United States. Management of disseminated metastatic CRC involves various active drugs, either in combination or as single agents. The choice of therapy is based on consideration of the goals of therapy, the type and timing of prior therapy, the mutational profile of the tumor, and the differing toxicity profiles of the constituent drugs. This manuscript summarizes the data supporting the systemic therapy options recommended for metastatic CRC in the NCCN Guidelines for Colon Cancer.

AbstractBackgroundObesity worsens various gastrointestinal pathologies. While bariatric surgery ameliorates obesity, it substantially modifies the gastrointestinal system depending on surgery type, with limited data on subsequent impact on obesity‐related gastrointestinal admissions.MethodsUsing the 2012–2014 Nationwide Readmission Database, we included individuals with obesity who received vertical sleeve gastrectomy (VSG), Roux‐en‐Y gastric bypass (RYGB), or hernia repair (HR–control surgery). Our main focus was the adjusted odds ratio (aOR) for gastrointestinal inpatient admissions within 6 months following surgery compared to the 6 months preceding it, while controlling for several confounding factors. Gastrointestinal admissions were grouped into postoperative complications or obesity‐associated gastrointestinal conditions.ResultsOur cohort included 140,103 adults with RYGB, 132,253 with VSG, and 12,436 HR controls. Postoperative gastrointestinal complications were most common after RYGB, prominently obstruction (aOR = 33.17, 95%CI: 18.01, 61.10), and Clostridium difficile infection (aOR: 12.52, 95%CI: 6.22, 25.19). VSG also saw significantly increased but less frequent similar conditions. Notably, for gastrointestinal conditions associated with obesity, acute pancreatitis risk was higher post‐VSG (aOR = 6.26, 95%CI: 4.02, 9.73). Post‐RYGB patients were most likely to be admitted for cholelithiasis with cholecystitis (aOR: 4.15, 95% CI: 3.24, 5.31), followed by chronic liver disease (aOR: 3.00, 95% CI: 2.33, 3.87). The risk of noninfectious colitis admissions was threefold higher after RYGB and VSG. No gastrointestinal conditions showed an increase after HR.ConclusionDespite weight loss, bariatric surgery was associated with an increased risk of hepato‐pancreatobiliary and colitis admissions related to obesity in the first six postoperative months, with considerable variations in rates of gastrointestinal conditions by surgery type.

This discussion summarizes the NCCN Clinical Practice Guidelines for managing squamous cell anal carcinoma, which represents the most common histologic form of the disease. A multidisciplinary approach including physicians from gastroenterology, medical oncology, surgical oncology, radiation oncology, and radiology is necessary. Primary treatment of perianal cancer and anal canal cancer are similar and include chemoradiation in most cases. Follow-up clinical evaluations are recommended for all patients with anal carcinoma because additional curative-intent treatment is possible. Biopsy-proven evidence of locally recurrent or persistent disease after primary treatment may require surgical treatment. Systemic therapy is generally recommended for extrapelvic metastatic disease. Recent updates to the NCCN Guidelines for Anal Carcinoma include staging classification updates based on the 9th edition of the AJCC Staging System and updates to the systemic therapy recommendations based on new data that better define optimal treatment of patients with metastatic anal carcinoma.

INTRODUCTION: Intragastric balloons (IGBs) are a safe and effective treatment for obesity. However, limited knowledge exists on the underlying biological changes with IGB placement. METHODS: This single-institution study was part of an adjustable IGB randomized controlled trial. Subjects with obesity were randomized in a 2 is to 1 ratio to 32 weeks of IGB with diet/exercise counseling (n = 8) vs counseling alone (controls, n = 4). Diet/exercise counseling was continued for 24 weeks post-IGB removal to assess weight maintenance. We used mass spectrometry for nontargeted plasma lipidomics analysis and 16S rRNA sequencing to profile the fecal microbiome. RESULTS: Subjects with IGBs lost 15.5% of their body weight at 32 weeks vs 2.59% for controls ( P < 0.05). Maintenance of a 10.5% weight loss occurred post-IGB explant. IGB placement, followed by weight maintenance, led to a −378.9 μM/L reduction in serum free fatty acids compared with pre-IGB (95% confidence interval: 612.9, −145.0). This reduction was mainly in saturated, mono, and omega-6 fatty acids when compared with pre-IGB. Polyunsaturated phosphatidylcholines also increased after IGB placement (difference of 27 μM/L; 95% confidence interval: 1.1, 52.8). Compared with controls, saturated and omega-6 free fatty acids (linoleic and arachidonic acids) were reduced after IGB placement. The fecal microbiota changed post-IGB placement and weight maintenance vs pre-IGB ( P < 0.05). Further analysis showed a possible trend toward reduced Firmicutes and increased Bacteroidetes post-IGB and counseling, a change that was not conclusively different from counseling alone. DISCUSSION: IGB treatment is associated with an altered fecal microbiome profile and may have a better effect on obesity-related lipidome than counseling alone.

INTRODUCTION: Bariatric surgery (BRS) is an effective weight loss method that should, in theory, improve many gastrointestinal, liver, and pancreatic (GILP) diseases seen with obesity. At the same time, there is an increased morbidity related to BRS’s gastrointestinal alterations. Thus, we examined the short-term impact of BRS type on admission rates of various GILP diseases. METHODS: We queried the 2012-2014 Nationwide Readmission Database to identify obese patients who underwent vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RYGB), or, as a control, hernia repair surgery (HR). Our primary aim was to compare rates of GILP diseases within 6 months post- and 6 months pre-surgery in the VSG, RYGB, and HR cohorts. In a time to event analysis we evaluated readmission rates up to 11 months post-BRS. RESULTS: We identified a total of 140,103 patients in the VSG cohort, 132,253 patients in the RYGB cohort, and 12,436 patients in the HR cohort. HR patients were slightly older with a higher percentage of Medicare insurance carriers in contrast to VSG and RYGB (Table 1). RYGB was associated with a 33-fold increased risk of intestinal obstructions compared to pre-RYGB ( P < 0.001). Other notably increased GILP diseases after RYGB from highest to lowest risk (Table 2): C. difficile infection [adjusted odds ratio (aOR): 12.52, P < 0.001], GI hemorrhage (aOR: 10.95, P < 0.001), biliary disease (aOR: 4.15, P < 0.001) and functional/motility disorders (aOR: 3.57, P < 0.001). In contrast, post- versus pre-VSG patients were most frequently admitted for acute pancreatitis (aOR: 6.26, P < 0.001), followed by C. difficile infection (aOR: 4.86, P < 0.001), biliary disease (aOR: 3.14, P < 0.001), noninfectious gastroenteritis (aOR: 3.05, P < 0.001) and functional/motility disorders (aOR: 2.74, P < 0.001). No increase in admissions was observed in the control HR cohort for any of these diseases. In our time to event analysis, the probability of being admitted was most notable for intestinal obstructions within 30 days after RYGB while functional disorders predominate afterwards (Figure 1). Similarly, patients were more frequently admitted for functional disorders following VSG. CONCLUSION: The type of BRS has a differential impact on GILP admissions after surgery. There may be a limited impact of weight loss on functional disorders that seem to dominate irrespective of BRS type. This data can help better inform patients on the choice of surgery to pursue, however more data are warranted.