Colibaseanu, Dorin T

Background Venous thromboembolism (VTE) is the most common cause of preventable mortality following colorectal surgery (CRS), occurring in about 2% of patients. As a result, prophylaxis including discharge chemoprophylaxis is recommended. While VTE risk assessment tools are available, the consistent adoption and utilization of these tools remains elusive. Our study objectives were to determine the utilization and impact of risk adjusted VTE prophylaxis in CRS patients. Study Design CRS cases performed between 1/1/2016 and 5/31/2021 were retrospectively analyzed. Caprini score and implemented VTE prophylaxis measures were determined. The primary outcome measure was receiving Caprini guideline indicated VTE prophylaxis. Secondary outcomes included VTE and bleeding. Categorical variables were compared by chi-square and Fisher’s exact tests, and continuous variables by Kruskal-Wallis test. Logistic regression models were used to determine predictors of receiving appropriate VTE prophylaxis or experiencing postoperative VTE and bleeding. Results 10,422 CRS cases were analyzed and 90.6% were high risk for VTE. In-hospital appropriate prophylaxis rates in low, moderate, high, and very high-risk category patients were 91.2%, 56.1%, 61.0%, and 63.1%, respectively. Inpatient VTE was reduced by 75% in those receiving appropriate VTE prophylaxis. At discharge, 5.8% of patients received appropriate prophylaxis, in whom there were no VTE events at 30- and 90 days from discharge. Increasing Caprini score positively correlated with VTE risk in both the inpatient and discharge cohorts, but inversely correlated with the likelihood of receiving appropriate prophylaxis at discharge (OR .31, P <.0001). Conclusion Caprini guideline indicated VTE prophylaxis in CRS patients reduced VTE events without increasing bleeding complications.

Abstract Background There is controversy regarding the postoperative outcomes in Crohn’s disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy. Methods All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon’s discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications. Results A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease. Conclusions This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn’s disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn’s disease. Further studies with larger sample sizes are needed to confirm results.

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)

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.

AbstractIleocolic resection (ICR) is the most common surgical procedure in Crohn disease (CD). There are many surgical techniques for performing ICRs and subsequent anastomoses. Recurrence of CD after ICR is common, often clinically silent, and thus requires monitoring including periodic use of endoscopy to detect early active disease. There is emerging evidence that surgical approaches may influence CD recurrence. This review explores the various surgical considerations, the data behind each decision, and how these techniques influence subsequent endoscopic surveillance.

AbstractBackground and ObjectiveWhether bowel preparation utilization rates or effectiveness varies based on tumor location is unknown.MethodsThe 2012–2016 American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted participant user file was queried for patients undergoing elective colorectal resection for cancer. Bowel preparation was classified as combined, mechanical bowel preparation alone, oral antibiotic alone, or none. Cochran–Armitage tests were used for trend analysis. Multivariable analyses stratified by tumor location were performed for the outcome of anastomotic leak. An additional multivariable model including all tumor locations assessed for interaction between bowel preparation and tumor location on an anastomotic leak.ResultsA total of 29,739 operations were included and the anastomotic leak rate was 1.9% with combined preparation versus 4.0% without preparation. Combined bowel preparation utilization increased over time as tumor location became more distal (both p < .0001). However, the adjusted effect of combined bowel preparation on anastomotic leak risk reduction did not differ by individual tumor location or across all tumor locations (p = .43 for interaction).ConclusionThough the utilization rate of combined bowel preparation increased as tumor location became more distal, its risk‐reducing effect remained similar. Quality improvement initiatives should focus on increased utilization of combined bowel preparation with an emphasis on tumors in the ascending colon.

Objective: To compare short term outcomes of patients undergoing laparoscopic or robotic rectal cancer surgery. Background: Significant benefits of robotic rectal cancer surgery over laparoscopy have yet to be demonstrated. Operative time and direct institutional cost seem in favor of the laparoscopic approach. Methods: We performed a retrospective review of consecutive patients operated on for rectal cancer with a mini-invasive approach at Mayo Clinic from 2005 to 2018. The primary aim of this study was to investigate the difference in postoperative morbidity between the laparoscopic and robotic approach. Multivariable models for odds to complications and prolonged (≥6 days) length of stay were built. Results: A total of 600 patients were included in the analysis. The number of patients undergoing robotic surgery was 317 (52.8%). The 2 groups were similar in respect to age, sex, and body mass index. Laparoscopic surgery was correlated to shorter operative time (214 vs 324 minutes; P < 0.001). Patients undergoing robotic surgery had a lower overall complications rate (37.2% vs 51.2%; P < 0.001). Robotic surgery was found to be the most protective factor [odds ratio (OR) 0.485; P = 0.006] for odds to complications. The event of a complication (OR 9.33; P < 0.001) and conversion to open surgery (OR 3.095; P = 0.002) were identified as risk factors for prolonged length of stay whereas robotic surgery (OR 0.62; P = 0.027) was the only independent protective factor. Conclusions: Robotic rectal cancer surgery is strongly associated with better short-term outcomes over laparoscopic surgery.

Abstract Background: Laparoscopy and more recently robotics are increasingly used for colorectal cancer surgery in the United States. We examined the current trends of minimally invasive surgical resections for colorectal cancer in Florida. Methods: The Florida Inpatient Discharge Dataset was used to examine the clinical data of patients who underwent elective surgery for colorectal cancer during 2013–2015. Multivariate analyses were performed to compare patient characteristics associated with the use of open and minimally invasive surgeries. Results: A total of 10,513 patients were analyzed; 5451 (52%) had open surgery, 4403 (42%) laparoscopy, and 659 (6%) robotic surgery. The rates of minimally invasive surgery (MIS) increased from 46.95% in 2013 to 48.72% in 2015. Among minimally invasive surgical procedures, the use of robotics increased from 9.82% in 2013 to 15.48% in 2015. Metastatic cancer (odds ratio [OR] 0.61, confidence interval [CI] 0.55–0.67), Elixhauser score of 3–5 (OR 0.85, CI 0.76–0.95) or more than 5 (OR 0.78, CI 0.63–0.97), Medicaid insurance (OR 0.73, CI 0.6–0.89), Black race (OR 0.88, CI 0.77–0.99), and rural residence (OR 0.83, CI 0.69–0.99) were associated with lower odds of MIS than open surgery. Conclusions: This study demonstrates that the overall rates of MIS for colorectal cancer in Florida increased from 2013 to 2015. Socially deprived and very sick patient populations with colorectal cancer are less likely to undergo MIS.

Background. Individuals after solid organ transplant may develop secondary malignancies. In our clinical practice, we noted an increasing number of individuals who developed colorectal cancers after solid organ transplantation. The primary aim of this study was to describe the characteristics and outcomes of the patients who developed colorectal cancer after solid organ transplant. Materials and Methods. Data was gathered and merged from several registries at Mayo Clinic to identify all patients who received a diagnosis of colon or rectal cancer and solid organ transplant. Continuous variables were summarized as mean (standard deviation) and median (range), while categorical variables were reported as frequency (percentage). Time to colorectal cancer after transplant and overall survival after cancer diagnosis were estimated using Kaplan-Meier method. Results. Initially, 115 colorectal cancer patients who also had a transplant were identified. The diagnosis of colorectal cancer was noted after solid organ transplant in 63 patients. The mean age at transplant was 57 years. Majority had received a kidney transplant (44.4%) followed by liver (36.5%). The median time to develop colorectal cancer was 59.3 months (range: 4.4-251.4 months). 15 (24.6%) were stage 4 at diagnosis and 13 (21.3%) had stage 3 colorectal cancer. Median overall survival was 30.8 months; 5-, 10- and 15-year survival were noted to be 42.5%, 17.9%, and 7.5%, respectively. None of the stage 4 patients were alive at 5 years; 5-year survival rate for stage 1, 2, and 3 patients was 77%, 50%, and 42%, respectively. Conclusions. Our study reports on one of the largest cohorts of patients of colorectal cancer that developed the cancer after solid organ transplant. Survival is extremely poor for advanced cases. However, long-term survivors are noted who developed the cancer at a relatively early stage. Colorectal screening recommendations may need to be revised for patients after solid organ transplant.