Broccard, Sacha P.

Abstract Introduction Ileal pouch–anal anastomosis (IPAA) is a common surgical procedure for patients with ulcerative colitis or familial adenomatous polyposis. This study compared the outcomes of robotic, laparoscopic, and open IPAA techniques, with a focus on surgical complications and pouch failure rates. Methods A retrospective study was conducted of patients who underwent IPAA at three Mayo Clinic locations between 2015 and 2020. Data on patient demographics, surgical details, and postoperative outcomes were collected and compared across the three surgical approaches. Pouch failure was defined as the need for pouch excision or a diverting loop ileostomy. Results In all, 401 patients underwent IPAA with either an open (149, 37.2%), robotic (145, 36.2%), or laparoscopic (107, 26.7%) technique. The overall rate of pouch failure was 6.5% and did not differ significantly between the three surgical approaches. Compared with laparoscopy, robotic IPAA was associated with a lower conversion rate to open surgery (1.4 versus 17.8%; P < 0.0001) and fewer 30-day readmissions (15.9% versus 28.0%; P = 0.02). However, robotic and laparoscopic IPAA approaches had higher rates of venous thromboembolism/pulmonary embolism and readmission than the open approach. Pouchitis was the most common cause of pouch failure across all surgical techniques. Conclusion Robotic IPAA had lower conversion and reduced 30-day admission rates compared with a laparoscopic approach. However, open surgery had lower rates of 30-day readmission and rates thromboembolism than robotic IPAA. The surgical approach itself does not appear to significantly impact long-term pouch failure rates.

BACKGROUND: Venous thromboembolism occurs in approximately 2% of patients undergoing abdominal and pelvic surgery for cancers of the colon, rectum, and anus and is considered preventable. The American Society of Colon and Rectal Surgeons recommends extended prophylaxis in high-risk patients, but there is low adherence to the guidelines. OBJECTIVE: This study aims to analyze the impact of venous thromboembolism risk-guided prophylaxis in patients undergoing elective abdominal and pelvic surgeries for colorectal and anal cancers from 2016 to 2021. DESIGN: This was a retrospective analysis. SETTING: The study was conducted at a multisite tertiary referral academic health care system. PATIENTS: Patients who underwent elective abdominal or pelvic surgery for colon, rectal, or anal cancer. MAIN OUTCOME MEASURES: Receipt of Caprini-guided venous thromboembolism prophylaxis, 90-day postoperative rate of deep vein thrombosis, pulmonary embolism, venous thromboembolism, and bleeding events. RESULTS: A total of 3504 patients underwent elective operations, of whom 2224 (63%) received appropriate thromboprophylaxis in the inpatient setting. In the postdischarged cohort of 2769 patients, only 2% received appropriate thromboprophylaxis and no thromboembolic events were observed. In the group receiving inappropriate thromboprophylaxis, at 90 days postdischarge, the deep vein thrombosis, pulmonary embolism, and venous thromboembolism rates were 0.60%, 0.40%, and 0.88%, respectively. Postoperative bleeding was not different between the 2 groups. LIMITATIONS: Limitations to our study include its retrospective nature, use of aggregated electronic medical records, and single health care system experience. CONCLUSION: Most patients in our health care system undergoing abdominal or pelvic surgery for cancers of the colon, rectum, and anus were discharged without appropriate Caprini-guided venous thromboembolism prophylaxis. Risk-guided prophylaxis was associated with decreased rates of inhospital and postdischarge venous thromboembolism without increased bleeding complications. See Video Abstract. MARGEN DE MEJORA: EL IMPACTO DE LA TROMBOPROFILAXIS RECOMENDADA POR LAS DIRECTRICES EN PACIENTES SOMETIDOS A CIRUGÍA ABDOMINAL POR CÁNCER COLORRECTAL Y ANAL EN UN CENTRO DE REFERENCIA TERCIARIO ANTECEDENTES: El tromboembolismo venoso ocurre en aproximadamente el 2% de los pacientes sometidos a cirugía abdominal y pélvica por cánceres de colon, recto y ano, y se considera prevenible. La Sociedad Estadounidense de Cirujanos de Colon y Recto recomienda una profilaxis prolongada en pacientes de alto riesgo, pero el cumplimiento de las directrices es bajo. OBJETIVO: Este estudio tiene como objetivo analizar el impacto de la profilaxis guiada por el riesgo de tromboembolismo venoso (TEV) en pacientes sometidos a cirugías abdominales y pélvicas electivas por cáncer colorrectal y anal entre 2016 y 2021. DISEÑO: Este fue un análisis retrospectivo. AJUSTE: El estudio se llevó a cabo en un sistema de salud académico de referencia terciaria de múltiples sitios. PACIENTES: Pacientes sometidos a cirugía abdominal o pélvica electiva por cáncer de colon, recto o ano. PRINCIPALES MEDIDAS DE RESULTADO: Recepción de profilaxis de tromboembolismo venoso guiada por Caprini, tasa postoperatoria de 90 días de trombosis venosa profunda, embolia pulmonar, tromboembolismo venoso y eventos de sangrado. RESULTADOS: Un total de 3.504 pacientes se sometieron a operaciones electivas, de los cuales 2.224 (63%) recibieron tromboprofilaxis adecuada en el ámbito hospitalario. En el cohorte de 2.769 pacientes después del alta, solo el 2% recibió tromboprofilaxis adecuada en la que no se observaron eventos tromboembólicos. En el grupo que recibió tromboprofilaxis inadecuada, a los 90 días después del alta, las tasas de trombosis venosa profunda, embolia pulmonar y tromboembolia venosa fueron del 0,60%, 0,40% y 0,88%, respectivamente. El sangrado posoperatorio no fue diferente entre los dos grupos. LIMITACIONES: Las limitaciones de nuestro estudio incluyen su naturaleza retrospectiva, el uso de registros médicos electrónicos agregados y la experiencia de un solo sistema de atención médica. CONCLUSIÓN: La mayoría de los pacientes en nuestro sistema de salud sometidos a cirugía abdominal o pélvica por cánceres de colon, recto y ano fueron dados de alta sin una profilaxis adecuada de TEV guiada por Caprini. La profilaxis guiada por el riesgo se asoció con menores tasas de tromboembolismo venoso hospitalario y dado de alta sin un aumento de las complicaciones de sangrado. (Traducción—Dr. Aurian Garcia Gonzalez)

Abstract Aim The aim of this study was to describe the surgical management, outcomes and risk of malignancy of presacral tailgut cysts. Method A retrospective analysis of all patients who underwent resection of tailgut cyst at Mayo Clinic in Arizona, Florida and Minnesota between 2008 and 2020 was performed. Demographics, presentation, evaluation, surgical approach, postoperative complications, pathology and recurrence rates were reviewed. Results Seventy‐three patients were identified (81% female) with a mean age of 45 years. Thirty‐nine patients (53%) were symptomatic, most commonly with pelvic pain (26 patients). Digital rectal examination identified a palpable mass in 68%. Mean tumour size was 6 cm. Resection was primarily performed through a posterior approach (77%, n = 56), followed by a transabdominal approach (18%, n = 13) and a combined approach (5%, n = 4). Six patients underwent a minimally invasive resection (laparoscopic/robotic). Coccygectomy or distal sacrectomy was performed in 41 patients (56%). Complete resection was achieved in 94% of patients. Thirty‐day morbidity occurred in 18% and was most commonly wound related; there was no mortality. Malignancy was identified in six patients (8%). For the 30 patients with follow‐up greater than 1 year, the median follow‐up was 39 months (range 1.0–11.1 years). Local recurrence was identified in three patients and distant metastatic disease in one patient. Conclusion The rate of malignancy in presacral tailgut cysts based on this current review was 8%. Overall recurrence was 5% at a median of 24 months.

With the incidence of breast cancer steadily rising, it is important to explore novel technologies that can allow for earlier detection of disease as well more a personalized and effective treatment approach. The concept of “liquid biopsies” and the data they provide have been increasingly studied in the recent decades. More specifically, circulating tumor DNA (ctDNA) has emerged as a potential biomarker for various cancers, including breast cancer. While methods such as mammography and tissue biopsies are the current standards for the detection and surveillance of breast cancer, ctDNA analysis has shown some promise. This review discusses the versatility of ctDNA by exploring its multiple emerging uses for the management of breast cancer. Its efficacy is also compared to current biomarkers and technologies.

Introduction: Central venous access using peripherally inserted central catheters is frequently used for patients receiving intravenous medications in the hospital or outpatients. Although there are several benefits of peripherally inserted central catheters, such as ease of insertion, low procedure-related risk and higher patient satisfaction, there are complications associated with peripherally inserted central catheter use. Despite some studies evaluating peripherally inserted central catheter line–related complications, the factors associated with peripherally inserted central catheter–related deep venous thrombosis in critically ill medical-surgical patients are poorly described. The objective of this case-control study was to identify the risk factors associated with peripherally inserted central catheter line–related deep venous thrombosis in critically ill medical-surgical intensive care unit patients in a community hospital. Methods: We abstracted relevant clinical data from 21 cases with symptomatic peripherally inserted central catheter–related deep venous thrombosis and 42 controls with peripherally inserted central catheters but no deep venous thrombosis. Results: Of the factors evaluated, female gender, the use of triple lumen peripherally inserted central catheters, larger outer diameter, and open (vs valve) peripherally inserted central catheters were associated with venous thrombosis. In this retrospective study, we did not identify any association of peripherally inserted central catheter–related deep venous thrombosis with a prior history of deep venous thrombosis, use of alteplase, antiplatelet therapy, prophylactic or therapeutic anticoagulation, international normalized ratio, platelet count and the use of peripherally inserted central catheters for total parenteral nutrition. Conclusion: Our study indicates that the catheter size relative to the diameter of the vein could be an important risk factor for the development of peripherally inserted central catheter–related deep venous thrombosis. The study findings should be confirmed in a larger study designed to identify risk factors of peripherally inserted central catheter–related deep venous thrombosis. In the meantime, the peripherally inserted central catheter lines should be used judiciously in critically ill patients.