Mathis, Kellie L.

BACKGROUND: Although the safety of laparoscopic redo ileocolonic resection for Crohn’s disease has been described before, the safety of robotic redo ileocolonic resection is still unelucidated. OBJECTIVE: This study aimed to share our preliminary experience regarding the safety of robotic redo ileocolonic resection for Crohn’s disease. DESIGN: Retrospective analysis. SETTING: Tertiary care center. PATIENTS: All consecutive adult patients who underwent robotic ileocolonic resection for Crohn’s disease at our institution between 2014 and 2021 were included. Patients were divided into redo ileocolonic resection and primary ileocolonic resection groups. PRIMARY OUTCOME MEASURES: Baseline demographics, preoperative risk factors, and intraoperative details were compared between both groups. The primary outcome was conversion to an open approach, and secondary outcomes were 30-day postoperative complications. RESULTS: A total of 98 patients were included. Of them, 18 (18.4%) had a redo ileocolonic resection. Patients who had a redo ileocolonic resection were more likely to have a longer duration of disease, associated anoperineal disease, a higher number of previous lines of medical treatments, received total parental nutrition before the operation for correction of malnutrition, and longer time for adhesiolysis. Patients who had redo ileocolonic resection had a higher risk for conversion to open ileocolonic resection [3 (16.7%) versus 2 (2.5%); p value = 0.04]. There was no statistically significant difference regarding the overall length of stay and the 30-day morbidity between both groups. No 30-day mortality or anastomotic leaks occurred in either group. LIMITATIONS: Retrospective nature of the analysis. CONCLUSIONS: Robotic redo ileocolonic resection showed similar short-term postoperative outcomes to robotic primary ileocolonic resection for Crohn’s disease. However, conversion rates are higher in robotic redo ileocolonic resection yet seem lower than previously published results in laparoscopic surgery. See Video Abstract at http://links.lww.com/DCR/C77. RESECCIÓN ILEOCÓLICA ROBÓTICA REDO PARA LA ENFERMEDAD DE CROHN: INFORME PRELIMINAR DE UN CENTRO DE ATENCIÓN TERCIARIA ANTECEDENTES: Si bien la seguridad de la resección ileocolónica laparoscópica para la enfermedad de Crohn se ha descrito antes, la seguridad de la resección ileocolónica robótica aún no se ha dilucidado. OBJETIVO: Este estudio tuvo como objetivo compartir nuestra experiencia preliminar con respecto a la seguridad de la resección ileocolónica robótica para la enfermedad de Crohn. DISEÑO: Análisis retrospectivo. AJUSTE: Centro de atención terciaria. PACIENTES: Se incluyeron todos los pacientes adultos consecutivos que se sometieron a resección ileocolónica robótica por enfermedad de Crohn en nuestra institución entre 2014 y 2021. Los pacientes se dividieron en grupos de resección ileocolónica reconfeccionada y resección ileocolónica primaria. MEDIDAS DE RESULTADO: Se compararon los datos demográficos iniciales, los factores de riesgo preoperatorios y los detalles intraoperatorios entre ambos grupos. El resultado primario fue la conversión a abierto y los resultados secundarios fueron las complicaciones posoperatorias a los treinta días. RESULTADOS: Se incluyeron un total de 98 pacientes. De ellos, 18 (18,4%) tuvieron resección ileocolónica. Los pacientes que se sometieron a una nueva resección ileocolónica tenían más probabilidades de tener una mayor duración de la enfermedad, enfermedad anoperineal asociada, un mayor número de líneas previas de tratamientos médicos, más probabilidades de haber recibido nutrición parental total antes de la operación para la corrección de la desnutrición y más tiempo tiempo de adhesiolisis. Los pacientes que se sometieron a una nueva resección ileocolónica tuvieron un mayor riesgo de conversión a cirugía abierta [3 (16,7 %) frente a 2 (2,5 %); valor p 0,04]. No hubo diferencia estadísticamente significativa con respecto a la duración total de la estancia y la morbilidad a los treinta días entre ambos grupos. No hubo mortalidad a los treinta días ni fugas anastomóticas en ninguno de los grupos. LIMITACIONES: Naturaleza retrospectiva del análisis. CONCLUSIÓN: La resección ileocolónica robótica mostró resultados postoperatorios a corto plazo similares a la resección ileocolónica primaria robótica para la enfermedad de Crohn. Sin embargo, las tasas de conversión son más altas en la resección ileocolónica robótica, pero parecen más bajas que los resultados publicados previamente en la cirugía laparoscópica. Consulte Video Resumen en http://links.lww.com/DCR/C77. (Traducción—Dr Yolanda Colorado)

Background Renal transplant patients presenting with diverticulitis remain a clinical challenge for health care professionals. Secondary to immunosuppression, renal transplant recipients are often considered for early operative intervention due to concerns for an unreliable physical exam and feared morbidity and mortality associated with non-operative management. Methods This study aimed to evaluate trends in management of renal transplant patients with diverticulitis at a quaternary referral center. Results One hundred ninety-one renal transplant patients admitted to the hospital with diverticulitis were identified. Of this cohort, 71 (37%) underwent surgical resection, of which 20 (28%) were performed emergently. The overall 30-day operative mortality was 8% (6/71), of which there was a significant difference between emergent (25%, 5/20) and elective (2%, 1/51) groups ( P = .006). Patients who underwent elective surgery were more likely to receive a minimally invasive approach (51%) and were significantly more likely to undergo stoma reversal ( P = .006). Discussion Our study shows that not all renal transplants with diverticulitis will require operative intervention and many can be safely treated non-operatively. Elective resection and surgical management should be considered on an individual basis. Patients treated with elective resection were more likely to undergo a minimally invasive approach and restoration of intestinal continuity.

Lay SummaryEnterovesical fistula in Crohn’s disease that require surgery may be managed safely laparoscopically with similar morbidity to open repair and a shorter length of stay. Preoperative biologic exposure does not affect surgical morbidity.

Abstract Background Proctectomy is often recommended when Crohn’s proctitis becomes refractory to medical therapy. However, some surgeons offer a temporary diverting stoma in an effort to avoid a permanent stoma. The long-term efficacy of this approach is not well-established. Our aim was to determine the long-term effectiveness of fecal diversion in patients with refractory Crohn’s proctitis. Methods This retrospective study included all patients with Crohn’s proctitis who underwent formation of a diverting ileostomy or colostomy for refractory disease from, 1998 to, 2019 in Mayo Clinic Rochester MN. Outcomes were disease recurrence, rate of stoma closure, and proctectomy. Univariate comparisons among categorical variables were performed with Pearson’s Chi-square and continuous variables using the student t-test. The cumulative probability of stoma closure was performed with a Kaplan Meier log-rank analysis. Multivariable analysis of risk factors for proctectomy and permanent stoma was achieved with logistic regression. Results Ninety-seven patients (55.7% female) were included. Ileostomy was the most common stoma type (88.7%, n=86), and colostomy was (11.3%, n=11) (Table.1). Median follow-up was, 4 years (range, 0–14). Active Crohn’s at follow-up was reported in, 68.1%. Only, 41.2% of patients underwent attempt at stoma reversal, and, 42.3% required a proctectomy (median, 19.5 months after diversion). At last follow-up, 29.9% were stoma-free, 42.3% had a new permanent stoma, and, 27.8% had the original diverting stoma (Fig.1). The multivariable predictors of proctectomy and permanent stoma were the recurrence of active CD after diversion and the need for other CD-related surgery following stoma creation (Table.2). The limitations of the study are its small sample size and its retrospective nature. The cumulative probability of stoma closure was performed with a Kaplan Meier log-rank analysis (Fig.2). Conclusion Diversion is effective at alleviating symptoms of Crohn’s proctitis in selected patients but does not significantly change disease outcome. Only a small number can avoid a long-term stoma.

Abstract Background Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in patients with Crohn’s disease (CD) and it is safe and feasible even in complex cases. However, an open approach is still required, but indications to open ileocolic resection for CD are not well described. Methods All consecutive adult patients with CD who underwent elective ileocolic resection in the Departments of Colon and Rectal Surgery at Mayo Clinic Rochester, Minnesota and Jacksonville, Florida between September 2014 and March 2021 were included and divided into “open” and “MIS” groups. Open approach was defined as upfront laparotomy, MIS included laparoscopic and robotic approaches, and conversion was defined as incision made earlier than planned. Indications to open approach were retrospectively reviewed by two authors, and any incongruity was resolved. Analogous indications were also assessed in the MIS group, as appropriate. Indications, baseline, perioperative characteristics, and short-term postoperative outcomes were compared between open and MIS. Results Among 319 ileocolic resections for CD, 45 (14.1%) were open and 274 (85.9%) MIS. Indications for open approach were severe disease, adhesions at previous surgery, history of abdominal sepsis, multifocal and extensive disease, abdominal wall involvement, concomitant open procedures, small bowel dilatation, and anaesthesiologic contraindications (Table 1). In addition, two or more of the above indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p<0.001). Compared to MIS patients, patients undergoing open ileocolic resection were older, with longer CD duration, more previous surgery and preoperative intra-abdominal abscess drainage (Table 2). Nine patients were converted in the MIS group (3.3%). Intraoperatively, open group had more adhesiolysis ≥45 min, more intraoperative complications, more blood loss, more primary stoma, less anastomosis, and longer operative time (Table 3). Postoperatively, they had more overall postoperative complications, ileus, surgical site infections, dehydration, vascular thromboembolism, higher severity by Clavien-Dindo classification, and longer length of stay (Table 4). Conclusion Overall rate of open approach ileocolic resection for CD was 14 % during a 7-years period in a referral centre. Open approach was the only operation performed in cases of abdominal wall involvement, concomitant open procedures, and anaesthesiologic contraindication. In addition, the presence of at least two indications,predicting high technical complexity, may be considered as a no-go for the MIS approach in ileocolic resections for CD.

192 Background: Rectal cancer treatment paradigm has been evolving over time. Historically, for locally advanced rectal cancer, standard therapy (ST) consisted of neoadjuvant chemoradiation followed by surgery and adjuvant chemotherapy. Recently, total neoadjuvant treatment (TNT) approach that delivers both neoadjuvant chemotherapy (CAPOX or FOLFOX) and chemoradiation (or radiation only) prior to surgery is increasingly being utilized. The prognostic and predictive values of mismatch repair deficient (dMMR) in rectal cancer is not well characterized. Most dMMR patients receive the same treatment as MMR proficient (pMMR) patients although there is limited data that dMMR rectal cancer patients may not have the same level of benefits from neoadjuvant treatment. This retrospective study aims to evaluate the clinicopathological/molecular characteristics, disease response, and clinical outcomes in dMMR localized rectal cancer patients. Methods: A retrospective analysis was conducted on consecutive adult patients with a diagnosis of dMMR rectal cancer who were treated at Mayo Clinic between January 2000 to September 2021. Patients who presented with concurrent primary non-colorectal malignancies were excluded. The distributions of demographics, clinicopathological features, biomarkers, and outcome data were collected. Survival was assessed using Kaplan-Meier curves and Cox models were stratified by treatment arms to determine significance of treatment strategies. Results: Forty-one patients were identified with a median age of 45.3 years. Thirty (73.2%) pts were male. The most common MMR were loss of MSH2 and MSH6 (12/42; 29.3%) followed by loss of MLH1 and PMS2 (10/42; 24.4%) and solitary loss of MSH2 (4/42; 9.8%). The treatment, pathological response, and clinical outcomes are listed in table. With a median follow up of 101 months, only 6 patients (14.3%) died and median overall survival was not reached. Conclusions: Our findings showed dMMR localized rectal cancer responded to both ST and TNT with good clinical outcomes.[Table: see text]

BACKGROUND: Intraoperative frozen-section analysis provides real-time margin resection status that can guide intraoperative decisions made by the surgeon and radiation oncologist. For patients with locally recurrent rectal cancer undergoing surgery and intraoperative radiation therapy, intraoperative re-resection of positive margins to achieve negative margins is common practice. OBJECTIVE: This study aimed to assess whether re-resection of positive margins found on intraoperative frozen-section analysis improves oncologic outcomes. DESIGN: This is a retrospective cohort study. SETTINGS: This study was an analysis of a prospectively maintained multicenter database. PATIENTS: All patients who underwent surgical resection of locally recurrent rectal cancer with intraoperative radiation therapy between 2000 and 2015 were included and followed for 5 years. Three groups were compared: initial R0 resection, initial R1 converted to R0 after re-resection, and initial R1 that remained R1 after re-resection. Grossly positive margin resections (R2) were excluded. MAIN OUTCOME MEASURES: The primary outcome measures were 5-year overall survival, recurrence-free survival, and local re-recurrence. RESULTS: A total of 267 patients were analyzed (initial R0 resection, n = 94; initial R1 converted to R0 after re-resection, n = 95; initial R1 that remained R1 after re-resection, n = 78). Overall survival was 4.4 years for initial R0 resection, 2.7 years for initial R1 converted to R0 after re-resection, and 2.9 years for initial R1 that remained R1 after re-resection (p = 0.01). Recurrence-free survival was 3.0 years for initial R0 resection and 1.8 years for both initial R1 converted to R0 after re-resection and initial R1 that remained R1 after re-resection (p ≤ 0.01). Overall survival did not differ for patients with R1 and re-resection R1 or R0 (p = 0.62). Recurrence-free survival and freedom from local re-recurrence did not differ between groups. LIMITATIONS: This study was limited by the heterogeneous patient population restricted to those receiving intraoperative radiation therapy. CONCLUSIONS: Re-resection of microscopically positive margins to obtain R0 status does not appear to provide a significant survival advantage or prevent local re-recurrence in patients undergoing surgery and intraoperative radiation therapy for locally recurrent rectal cancer. See Video Abstract at http://links.lww.com/DCR/B886. LA RE-RESECCIÓN DE LOS MÁRGENES MICROSCÓPICAMENTE POSITIVOS ENCONTRADOS DE MANERA INTRAOPERATORIA MEDIANTE LA TÉCNICA DE CRIOSECCIÓN, NO DA COMO RESULTADO UN BENEFICIO DE SUPERVIVENCIA EN PACIENTES SOMETIDOS A CIRUGÍA Y RADIOTERAPIA INTRAOPERATORIA PARA EL CÁNCER RECTAL LOCALMENTE RECIDIVANTE ANTECEDENTES: El análisis de la ténica de criosección para los margenes positivos encontrados de manera intraoperatoria proporciona el estado de la resección del margen en tiempo real que puede guiar las decisiones intraoperatorias tomadas por el cirujano y el oncólogo radioterapeuta. Para los pacientes con cáncer de recto localmente recurrente que se someten a cirugía y radioterapia intraoperatoria, la re-resección intraoperatoria de los márgenes positivos para lograr márgenes negativos es una práctica común. OBJETIVO: Evaluar si la re-resección de los márgenes positivos encontrados en el análisis de la ténica por criosecciónde manera intraoperatorios mejora los resultados oncológicos. DISEÑO: Estudio de cohorte retrospectivo. AJUSTES: Análisis de una base de datos multicéntrica mantenida de forma prospectiva. POBLACIÓN: Todos los pacientes que se sometieron a resección quirúrgica de cáncer de recto localmente recurrente con radioterapia intraoperatoria entre 2000 y 2015 fueron incluidos y seguidos durante 5 años. Se compararon tres grupos: resección inicial R0, R1 inicial convertido en R0 después de la re-resección y R1 inicial que permaneció como R1 después de la re-resección. Se excluyeron las resecciones de márgenes macroscópicamente positivos (R2). PRINCIPALES MEDIDAS DE RESULTADO: Supervivencia global a cinco años, supervivencia sin recidiva y recidiva local. RESULTADOS: Se analizaron un total de 267 pacientes (resección inicial R0 n = 94, R1 inicial convertido en R0 después de la re-resección n = 95, R1 inicial que permaneció como R1 después de la re-resección n = 78). La supervivencia global fue de 4,4 años para la resección inicial R0, 2,7 años para la R1 inicial convertida en R0 después de la re-resección y 2,9 años para la R1 inicial que permaneció como R1 después de la re-resección (p = 0,01). La supervivencia libre de recurrencia fue de 3,0 años para la resección inicial R0 y de 1,8 años para el R1 inicial convertido en R0 después de la re-resección y el R1 inicial que permaneció como R1 después de la re-resección (p ≤ 0,01). La supervivencia global no difirió para los pacientes con R1 y re-resección R1 o R0 (p = 0,62). La supervivencia libre de recurrencia y la ausencia de recurrencia local no difirieron entre los grupos. LIMITACIONES: Población de pacientes heterogénea, restringida a aquellos que reciben radioterapia intraoperatoria. CONCLUSIONES: La re-resección de los márgenes microscópicamente positivos para obtener el estado R0 no parece proporcionar una ventaja de supervivencia significativa o prevenir la recurrencia local en pacientes sometidos a cirugía y radioterapia intraoperatoria para el cáncer de recto localmente recurrente. Consulte Video Resumen en http://links.lww.com/DCR/B886. (Traducción—Dr. Daniel Guerra)