Dozois, Eric J.

SAGE-Journals-Accessible-Video-Player 10.1089/vid.2012.0043.M1 sj-vid-1-vid-10.1089_vid.2012.0043

Abstract Background This study determined survival and recurrence rates following curative resection of rectal cancer without radiotherapy. Methods This was a retrospective review of the Mayo Clinic database of patients with rectal cancer treated with curative intent using surgery alone from 1990 to 2006. Patients who received neoadjuvant chemotherapy or radiation therapy and those who had any postoperative radiotherapy were excluded. Details were collected from the database and patient records using a protocol approved by the institutional review board. Results Some 655 consecutive patients with rectal cancer treated with curative intent using surgery alone were identified; 397 had stage I disease, 125 stage II and 133 stage III. Four hundred and nine patients underwent anterior resection (AR) and 246 abdominoperineal resection (APR). Median follow-up was 62 months. The 5-year rate of local recurrence was 4·3 per cent, disease-free survival 90·0 per cent and cancer-specific survival 91·5 per cent. Stage-specific and all-stage disease-free survival did not differ significantly between AR and APR. The 5-year cumulative local recurrence rate was lower following AR than APR (3·6 versus 5·5 per cent; P = 0·321). There were only two patients with positive margins and type of operation was not significant on multivariable analysis. Conclusion Well-performed, standardized APRs have similar local recurrence to AR. Radiation therapy may not confer much additional benefit. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Abstract Background Serrated polyps are an inhomogeneous group of lesions that harbour precursors of colorectal cancer. Current research has been directed at further defining the histopathological characteristics of these lesions, but definitive treatment recommendations are unclear. The aim was to review the current literature regarding classification, molecular genetics and natural history of these lesions in order to propose a treatment algorithm for surgeons to consider. Methods The PubMed database was searched using the following search terms: serrated polyp, serrated adenoma, hyperplastic polyp, hyperplastic polyposis, adenoma, endoscopy, surgery, guidelines. Papers published between 1980 and 2010 were selected. Results Sixty papers met the selection criteria. Most authors agree that recommendations regarding endoscopic or surgical management should be based on the polyp's neoplastic potential. Polyps greater than 5 mm should be biopsied to determine their histology so that intervention can be directed accurately. Narrow-band imaging or chromoendoscopy may facilitate the detection and assessment of extent of lesions. Complete endoscopic removal of sessile serrated adenomas in the left or right colon is recommended. Follow-up colonoscopy is recommended in 2–6 months if endoscopic removal is incomplete. If the lesion cannot be entirely removed endoscopically, segmental colectomy is strongly recommended owing to the malignant potential of these polyps. Left-sided lesions are more likely to be pedunculated, making them more amenable to successful endoscopic removal. Conclusion Even though the neoplastic potential of certain subtypes of serrated polyp is heavily supported, further studies are needed to make definitive endoscopic and surgical recommendations.

A rapid progression from conventional open surgery to minimally invasive approaches in the surgical management of colorectal cancer has occurred over the last 2 decades. Initial concerns that this new approach was oncologically inferior to open surgery were ultimately refuted when several prospective randomized trials concluded that laparoscopic colectomy could achieve similar oncologic outcomes to open surgery. On the contrary, level 1 data has not yet matured regarding the oncologic safety of minimally invasive approaches for rectal cancer. We review the published literature pertaining to the evolution of minimally invasive techniques used to treat colorectal cancer surgery, including barriers to adoption, and the prospects for future advances related to innovative techniques.

Abstract Background The role of minimally invasive surgery in complicated diverticulitis is still being elucidated. The aim of this study was to compare short-term outcomes in patients undergoing minimally invasive surgery for complicated or uncomplicated diverticular disease. Methods All patients who had elective minimally invasive surgery for diverticulitis between 2003 and 2008 were identified from a prospectively maintained database. Complicated disease was defined as diverticulitis associated with abscess, fistula, stricture or bleeding. Univariable analysis was performed to compare safety and short-term outcomes in patients with complicated and uncomplicated diverticulitis. Results A total of 361 patients (136 with complicated and 225 with uncomplicated diverticulitis) were operated on with either a laparoscopic (36·0 per cent) or a hand-assisted laparoscopic (64·0 per cent) surgical technique. There were no significant differences between the groups with respect to age, sex, body mass index, laparoscopic approach, postoperative recovery protocol or previous open surgery. Conversion rates were similar for complicated and uncomplicated disease (14·0 versus 11·6 per cent respectively; P = 0·514). There was no difference between the groups with respect to return of bowel function (mean 3·1 versus 3·2 days respectively; P = 0·156), morbidity (27·9 versus 19·6 per cent; P = 0·070) or mean length of stay (5·4 versus 4·8 days; P = 0·186). There were no deaths within 30 days. Conclusion Elective minimally invasive colectomy is feasible for patients with uncomplicated and complicated diverticulitis, with equivalent outcomes.

Abstract Background Presacral tailgut cysts are uncommon and few data exist on the outcomes following surgery. Methods Patients undergoing tailgut cyst resection at the Mayo Clinic between 1985 and 2008 were analysed retrospectively. Demographic data, clinicopathological features, operative details, postoperative complications and recurrence were reviewed. Results Thirty-one patients were identified (28 women), with a median age of 52 years. Seventeen patients were symptomatic and 28 had a palpable mass on digital rectal examination. Median cyst diameter was 4·4 cm. Four patients had a fistula to the rectum. Complete cyst excision was achieved in all patients; eight underwent distal sacral resection or coccygectomy. Postoperative complications occurred in eight patients but without 30-day mortality. Malignant transformation was present in four patients: adenocarcinoma in three and carcinoid in one. The cyst recurred in one patient after surgery for a benign lesion. Conclusion Presacral tailgut cysts should be removed due to the risk of malignant transformation.

Abstract Background The aim was to evaluate outcomes in patients with ulcerative colitis complicated by primary sclerosing cholangitis (PSC) who required ileal pouch–anal anastomosis (IPAA) and orthotopic liver transplantation (OLT). Methods A retrospective analysis was performed of 32 patients undergoing both IPAA and OLT between 1980 and 2006. Data were collected regarding demographics, indication for surgery, postoperative complications, and outcome of IPAA and OLT. Results Thirty-day mortality after either procedure was nil. The median preoperative Model for End-stage Liver Disease (MELD) score for the group with initial IPAA was 8 (range 6–20) and the postoperative score was 11 (range 6–19). At 1 and 10 years, 32 and 26 of the 32 liver grafts had survived, and 31 and 30 of the 32 pouches, respectively. Fourteen patients require daily medical therapy for chronic pouchitis. At a median follow-up of 3·6 (range 0·2–16·2) years after the second of two procedures, responding patients reported a median of 5·5 stools per day and 2 stools per night. Conclusion IPAA and OLT are feasible and safe in patients requiring both procedures for ulcerative colitis and PSC. Functional outcomes are stable over time, despite an increased risk of chronic pouchitis.

Object The operative management of combined intrapelvic and extrapelvic sciatic notch dumbbell-shaped tumors is challenging. The relatively rare occurrence of these tumors and the varied extent of disease have made it difficult for surgeons to establish definitive surgical indications or predict favorable neurological outcomes based on preoperative imaging data. Methods In the past 3 years, the authors treated five patients presenting with radiating leg pain as a result of benign sciatic notch dumbbell-shaped tumors. These tumors in three patients with unilateral leg symptoms were considered unresectable by other neurosurgeons because of presumed direct intrinsic neural involvement. After high-resolution magnetic resonance (MR) imaging demonstrated that the extensive tumors were separate from the sciatic nerve and the lumbosacral plexus, however, these patients underwent a combined one-stage transabdominal and posterior transgluteal complete resection. Normal neurological status was maintained postoperatively in these three patients, and after more than 1 year of postoperative follow up, there were no tumor recurrences. In two patients with bilateral symptoms and extensive tumor burden, serial MR images showed that innumerable tumors directly involved the entire cross-sectional area of the sciatic nerves and extended longitudinally to the lumbosacral plexuses. Tumor debulking or resection in these patients would have resulted in neurological deficits and would not have addressed their neuropathic pain, and therefore no surgery was performed. These two patients were treated pharmacologically and advised to monitor their tumor status over the course of their lifetimes in case of malignant transformation of the tumor. Conclusions A combined one-stage transabdominal and transgluteal approach allows safe resection of selected benign but extensive sciatic notch tumors. High-resolution MR imaging is a useful tool in the management of these tumors because it allows the surgeon to visualize the anatomical relationships of the tumor to the sciatic nerve. The authors believe that as this imaging technology advances, it will provide surgeons with a method to predict definitively which sciatic notch tumors displace rather than directly involve the sciatic nerve, and therefore indicate which tumors can be resected safely and completely.