Colibaseanu, Dorin

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.

Abstract Introduction The objective of the study was to investigate the characteristics of patients who underwent surgery for dysplasia detected during chromoendoscopy (CE) surveillance for inflammatory bowel disease (IBD) and the incidence of cancer in the surgical specimen. Methods A retrospective review of medical records of all patients with dysplasia on a background of underlying IBD diagnosed through CE was carried out at a tri-site enterprise tertiary referral center between 2006 and 2019. We aimed to assess the clinical characteristics of patients requiring surgery for dysplasia and the incidence of cancer in the surgical specimen. Results Out of 219 patients with dysplasia on CE, 35 underwent surgery for dysplasia (16%). Indications for surgery were multifocal disease (n = 6), endoscopically unresectable lesions (n = 13), visible HGD (n = 7) and unifocal invisible LGD (n = 9). Out of 35 patients requiring surgery, 5 were found to have adenocarcinoma, one of whom with stage IIIB disease received postoperative chemotherapy. No patient with a pathologic diagnosis of adenocarcinoma had any evidence of recurrent disease after a mean postoperative follow-up of 32 months. Conclusions While the incidence of cancer at the time of surgery for IBD-related dysplasia is not negligible, the rate of node-positive disease is low.

Objectives: Surgical site infections (SSIs) are the most common hospital-acquired infections in the United States, of which methicillin-resistant Staphylococcus aureus (MRSA) accounts for 43%. Preoperative povidone-iodine nasal swab (PNS) is considered an effective and cost-saving treatment for Staphylococcus aureus decolonization. We aim to assess the impact of preoperative PNS on SSI incidence. Materials and Methods: This retrospective observational study utilized elective surgical cases between January 1, 2018 and May 31, 2023, at a single academic medical center. The cohort was divided into PNS and no PNS groups. The cohort was propensity-matched, and Pearson χ2/Kruskal-Wallis tests were performed to compare group differences. Multivariable logistic regression was utilized to compare events between cohorts before and after matching. An alpha of <0.05 was considered significant. Results: A total of 45,998 (22,999 per group) matched participants were evaluated. On multivariate regression, the non-PNS treatment group was associated with an increase in hospital overall SSI occurrence (OR: 1.48, P = 0.02) but not specifically in-hospital methicillin-sensitive Staphylococcus aureus SSI, MRSA-SSI, or any 30-day SSI (P > 0.05). Compared with PNS treatment and prophylactic antibiotics, in-hospital SSI was higher in the absence of PNS treatment (OR: 1.83, P < 0.001), antibiotic (OR: 2.63, P < 0.001), or both (OR: 2.06, P < 0.01). Compared with PNS treatment plus prophylactic antibiotic, in-hospital MRSA-SSI was only higher in the absence of antibiotic (OR: 2.92, P < 0.01) treatment. Conclusions: Preoperative treatment with PNS may reduce overall in-hospital SSI but has no independent impact on MRSA SSI.

AbstractAimThe relationship between the number of stapler firings (SFs) during robotic rectal transection and the risk of colorectal/coloanal anastomotic leakage (AL) is controversial. This study investigates whether the number of robotic SFs is associated with an increased risk of AL.MethodRetrospective review of adult patients who underwent robotic total mesorectal excision (TME) and partial mesorectal excision (PME) with double‐stapled colorectal or coloanal anastomosis for both benign and malignant colorectal diseases between 2015 and 2023 across three enterprise‐wide hospitals. Primary outcome: the effect of multiple SFs on postoperative AL rate among patients who underwent one, two, or three or more SFs. Secondary outcome: the effects of other potential risk factors on postoperative AL.ResultsOf 503 patients who underwent robotic colorectal resection with a double‐stapled anastomosis, 56 (11%) developed a postoperative AL. The number of SFs was not associated with the AL rate (p = 0.51): the univariable and multivariate analyses found no correlation between the AL rate and the increasing number of SFs required, compared with one SF as the reference (adjusted two SFs, OR = 1.1, 95% CI: 0.6–2.2, p = 0.77 vs. adjusted three or more SFs, OR = 0.98, 95% CI: 0.4–2.3, p = 0.96). On multivariate analysis, AL was strongly associated with male gender (OR = 2.5, 95% CI: 1.3–4.9, p = 0.005) and with TME versus PME (OR = 2.8, 95% CI: 1.5–5.5, p = 0.002).ConclusionThe number of robotic SFs for rectal transection is not correlated with postoperative AL.

Abstract Aim Reversal of diverting loop ileostomy (DLI) traditionally occurs at ≥12 weeks after formation. Early closure has been performed in attempts to reduce DLI‐associated morbidity. Therefore, the aim of this study was to determine whether time to stoma reversal impacts postoperative morbidity. Method A retrospective review was conducted using institutional‐level American College of Surgeons National Surgical Quality Improvement Program data for adult patients who underwent DLI closure between January 2012 and December 2021 across a multistate health system. Time to DLI closure was stratified into three groups: ≤12, 12–24 or 24–36 weeks. Additional data were obtained from the electronic medical record. The primary outcome was major morbidity after DLI closure. Results A total of 482 patients underwent DLI closure. Eighty four patients underwent closure at ≤12 weeks (17.4%), 300 at 12–24 weeks (62.2%) and 98 at 24–36 weeks (20.3%). The most common diagnosis at DLI formation was cancer ( n = 211, 43.8%). Patients in the ≤12 weeks closure group more commonly had ulcerative colitis or diverticular disease and a lower American Society of Anesthesiologists class than patients with closure at 24–36 weeks ( p < 0.05). There were no significant differences in complication severity, overall major morbidity or its individual components amongst the time to DLI closure groups. There were no differences in anastomotic leaks or need for laparotomy. On multivariable analysis, immunosuppressive therapy and preoperative haematocrit <30% were significant risk factors for major morbidity after DLI closure. Conclusion Major morbidity did not differ by time to DLI closure group, indicating that closure at ≤12 weeks is safe in selected patients.

10 Background: Cell-free circulating tumor tissue modified viral DNA (ctDNA) has been used as a biomarker to detect recurrence for anal squamous cell carcinoma (ASCC). However, its value in informing treatment modification during definitive chemoradiation (CRT) has yet to be explored. We evaluated ctDNA response during and at completion of definitive CRT to establish patterns of disease response and inform future studies to personalize treatment. Methods: From 11/2022 to 6/2024, 13 consecutive patients with biopsy proven, non-metastatic ASCC received definitive CRT and had ctDNA testing using a commercially available droplet digital quantitative PCR assay. ctDNA testing was done at baseline (pre-CRT), week 4 of CRT, and/or end of CRT, 1-3 months post-CRT, and every 6 months thereafter. CRT included concurrent 5FU/MMC (or capecitabine/MMC) and radiotherapy according to RTOG 0529. Treatment response assessment included: physical exam, anoscopy, and imaging with PET/CT, CT C/A/P +/- MRI abdomen and pelvis. Results: 13 patients had ctDNA testing and 11 patients had HPV-positive ASCC and tested positive for ctDNA. The 11 patients with detectable baseline ctDNA were included in this analysis. The median age at diagnosis was 63 years old. Staging included: 1- Stage IIA, 7- Stage IIB, 1- Stage IIIA, 2- Stage IIIC. 1 patient was cN0, while 11 were cN1. With a median follow-up from completion of CRT of 13 months, 4 patients have persistent or recurrent disease: 2 with distant metastases, 1 with persistent local disease (1 month post-CRT), and 1 with local and distant recurrence. Baseline value of ctDNA did not correlate to stage at diagnosis, rate of clearance during CRT, or likelihood of recurrence. 5 of 11 patients cleared ctDNA by week 4 of CRT. Of 5 patients who cleared ctDNA by week 4 of CRT, 4 remain NED and 1 developed distant metastases. Of 6 patients with persistent ctDNA at week 4 of CRT, 3 have persistent or recurrent disease- 1 local persistence 1 month post-CRT, 1 local and distant recurrence 6 months post-CRT, and 1 with distant recurrence 12 months post- CRT. Among 6 patients who cleared ctDNA by the final week of CRT, 1 patient developed recurrent disease. Among the 4 patients in the series with residual/recurrent disease, 3 of them had not cleared ctDNA by the end of CRT. Of 10 patients with ctDNA testing at 1 month post-CRT, 8 had no detectable ctDNA. 2 patients with persistent (1) or recurrent (1) ctDNA at 1 month post-CRT developed disease recurrence- 1 with distant recurrence and 1 with local and distant recurrence. Conclusions: ctDNA assessment during CRT may provide insight into disease response that can predict patterns of failure and facilitate personalized therapy- treatment intensification, deintensification, or additional testing to detect early metastatic disease. Larger studies and clinical validation are needed.

AbstractAimCrohn's disease (CD) is regarded as a wasting disease, yet there is a growing population of CD patients with a body mass index (BMI) of 35 and above. The rate of postoperative complications is relatively high in CD patients but might be even higher in CD with morbid obesity (MO).MethodsThis was a retrospective study using a prospectively maintained database of all patients undergoing Ileocolic resection for CD between 2014 and 2021 in two referral centres, comparing postoperative complication rates according to BMI.ResultsThree hundred and forty‐six patients were identified. Sixty patients (17%) had a BMI over 30 kg/m2, and 28 (8.1%) had a BMI of over 35 kg/m2 (>35 group). The BMI >35 group had more women (78.6% vs. 52%, P < 0.1), a higher rate of patients not receiving an anastomosis (7.1% vs. 2.5%, P = 0.02), a higher rate of any postoperative surgical complication (32.1% vs. 25.2%, P = 0.4), with a higher rate of Clavien–Dindo ≥3 (14.3% vs. 7.2%, P = 0.25), a higher rate of stoma creation on reoperation for complications (7.2% vs. 1.7%, P = 0.04), a higher rate of 30‐day readmission due to intra‐abdominal abscess (10.7% vs. 4.7%, P = 0.2), but a lower rate of postoperative medical complications (3.6% vs. 15.7%, P < 0.01).ConclusionsThe rate of MO among CD patients requiring ileocolonic resection is on the rise. MO in this setting is associated with statistically non‐significant increases in all surgical complications, severe complications, readmission, and a higher chance for a bailout stoma creation upon reoperation. However, MO seems to be a protective factor for medical postoperative complications, which might suggest better nutritional status.

BACKGROUND: Concerns persist regarding the effectiveness of robotic proctectomy compared with open proctectomy for locally advanced rectal cancer with a high risk of circumferential resection margin involvement. OBJECTIVE: Comparison of surrogate cancer outcomes after robotic versus open proctectomy in this subpopulation. DESIGN: Retrospective cohort study. SETTING: Three academic hospitals (Mayo Clinic Arizona, Florida, and Rochester) with data available through the Mayo Data Explorer platform. PATIENTS: Patients at high risk of circumferential resection margin involvement were selected on the basis of the MRI-based definition from the MERCURY I and II trials. MAIN OUTCOME MEASURES: Rate of pathologic circumferential resection margin involvement (≤1 mm), mesorectal grading, and rate of distal margin involvement. RESULTS: Out of 413 patients, 125 (30%) underwent open and 288 (70%) underwent robotic proctectomy. Open proctectomy was significantly associated with a greater proportion of cT4 tumors (39.3% vs 24.8%, p = 0.021), multivisceral/concomitant resections (40.8% vs 18.4%, p < 0.001), and less frequent total neoadjuvant therapy use (17.1% vs 47.1%, p = 0.001). Robotic proctectomy was less commonly associated with pathologic circumferential resection margin involvement (7.3% vs 17.6%, p = 0.002), including after adjustment for cT stage, neoadjuvant therapy, and multivisceral resection (OR 0.326; 95% CI, 0.157–0.670, p = 0.002). Propensity score matching for 66 patients per group and related multivariable analysis no longer indicated any reduction of circumferential positive margin rate associated with robotic surgery ( p = 0.86 and p = 0.18). Mesorectal grading was comparable (incomplete mesorectum in 6% robotic proctectomy patients vs 11.8% open proctectomy patients, p = 0.327). All cases had negative distal resection margins. LIMITATION: Retrospective design. CONCLUSIONS: In patients with locally advanced rectal cancer at high risk of circumferential resection margin involvement, robotic proctectomy is an effective approach and could be pursued when technically possible as an alternative to open proctectomy. See Video Abstract . RESULTADOS COMPARATIVOS ENTRE LA PROCTECTOMÍA ROBÓTICA Y LA PROCTECTOMÍA ABIERTA EN CASOS DE CÁNCER DE RECTO CON ALTO RIESGO DE MÁRGEN DE RESECCIÓN CIRCUNFERENCIAL POSITIVO ANTECEDENTES: Persisten preocupaciones con respecto a la efectividad de la proctectomía robótica en comparación con la proctectomía abierta en casos de cáncer de recto localmente avanzado con un alto riesgo de margen de resección circunferencial positivo. OBJETIVO: Comparar los resultados en la subpoblación de portadores de cáncer luego de una proctectomía robótica versus una proctectomía abierta. DISEÑO: Estudio retrospectivo de cohortes. AJUSTE: Realizado en tres hospitales académicos (Mayo Clinic de Arizona, Florida y Rochester) a través de la plataforma Mayo Data Explorer. PACIENTES: Fueron seleccionados aquellos pacientes con alto riesgo de compromiso sobre el margen de resección circunferencial, según la definición de los Estudios Mercury I-II basada en la Imágen de Resonancia Magnética. MEDIDAS DE RESULTADO PRINCIPALES Y SECUNDARIAS: La tasa de compromiso patológico sobre el margen de resección circunferencial (≤1 mm), la clasificación mesorrectal y la tasa del compromiso del margen distal. RESULTADOS: De 413 pacientes, 125 (30%) fueron sometidos a una proctectomía abierta y 288 (70%) a proctectomía robótica. La proctectomía abierta se asoció significativamente con una mayor proporción de tumores cT4 (39,3% frente a 24,8%, p = 0,021), las resecciones multiviscerales/concomitantes fueron de 40,8% frente a 18,4%, p < 0,001 y una adminstración menos frecuente de terapia neoadyuvante total (17,1). % vs 47,1%, p = 0,001). La proctectomía robótica se asoció con menos frecuencia con la presencia de una lesión sobre el margen de resección circunferencial patológico (7,3% frente a 17,6%, p = 0,002), incluso después del ajuste por estadio cT, de la terapia neoadyuvante y de resección multivisceral (OR 0,326, IC 95% 0,157-0,670, p = 0,002). El apareado de propensión por puntuación en 66 pacientes por grupo y el análisis multivariable relacionado, no mostraron ninguna reducción en la tasa de margen positivo circunferencial asociado con la cirugía robótica ( p = 0,86 y p = 0,18). La clasificación mesorrectal fue igualmente comparable (mesorrecto incompleto en el 6% de los pacientes con RP frente al 11,8% de los pacientes con OP, p = 0,327). Todos los casos tuvieron márgenes de resección distal negativos. LIMITACIÓN: Diseño retrospectivo. CONCLUSIÓN: En pacientes con cáncer de recto localmente avanzado con alto riesgo de compromiso del margen de resección circunferencial, la proctectomía robótica es un enfoque eficaz y podría realizarse cuando sea técnicamente posible como alternativa a la proctectomía abierta. (Traducción—Dr. Xavier Delgadillo )