Outcomes of Simultaneous Versus Staged Resection for Stage IV Colorectal Cancer with Synchronous Liver Metastases.

INTRODUCTION: Management of stage IV colorectal cancer with synchronous liver metastases remains debated, as colorectal and liver resections can be performed simultaneously or staged apart. OBJECTIVE: This study aims to determine any demographic or outcome differences between simultaneous and staged resection. PARTICIPANTS: Retrospective review was performed on patients diagnosed with synchronous colorectal primary and liver metastases within Southern California Kaiser Permanente (KP) hospitals between 2010 and 2020. Patients with other metastases on diagnosis or those who did not receive both primary and liver resections were excluded. Demographic and outcome data were collected and analyzed. RESULTS: Of the 113 patients who met criteria, 72 (63.7%) received simultaneous and 41 (36.3%) received staged resection. Demographic data were comparable between simultaneous and staged resection, respectively, including median age of diagnosis, sex, and race. Both groups had similar median length of stay, percentage of major colorectal resection, and percentage of major liver resection. Both groups also had similar rates of radiation therapy, chemotherapy, and immunotherapy. There were no statistically significant difference in complications rates, median follow-up time, median overall survival, and median disease-free survival. CONCLUSIONS: Practice patterns within Southern California KP hospitals favor minor colorectal and liver resections. However, there were no significant differences in demographics, treatment rates, or outcomes between simultaneous and staged resection. While not statistically significant, our findings of a 11.9% higher major liver resection rate and 7.5-month longer median disease-free survival in the staged resection group may benefit from further study with higher power datasets.

Prophylactic Biosynthetic Retrorectus Mesh Placement During Stoma Reversal Reduces the Rate of Stoma Site Incisional Hernia.

INTRODUCTION: Stoma site incisional hernias (SSIHs) are associated with substantial long-term morbidity, and the rate can be as high as 30% to 40%. Recent efforts using prophylactic mesh reinforcement (PMR) to reduce the development of hernias have shown encouraging outcomes. The objective of this study was to assess the use of prophylactic biosynthetic mesh at the time of stoma reversal on the overall SSIH rate. METHODS: This is an observational retrospective cohort study. A review of 101 consecutive patients who underwent PMR in the retrorectus plane from 2015 to 2020 was compared to 73 consecutive patients who underwent primary stoma closure without mesh from 2011 to 2014. The primary endpoint was the presence of SSIH on clinical examination or computed tomography after ostomy takedown. RESULTS: In total, 174 cases were analyzed with 101 patients in the treatment group (median follow-up 45.2 months) and 73 patients in the control group (median follow-up 43.2 months). There were no major differences in preoperative characteristics between the groups. Fourteen patients developed SSIHs with 1 (1.0%) in the treatment arm and 13 (17.8%) in the control arm (p = 0.001). The majority of stomas were loop ileostomies and end colostomies, and stoma type did not affect hernia rates. On univariate analysis, body mass index (p = 0.029) and chronic kidney disease < 3 (p = 0.003) were independent predictors of hernia formation, while mesh was significantly protective (p = 0.000057). DISCUSSION: PMR with biosynthetic mesh at the time of stoma reversal and closure is an effective procedure to reduce the incidence of SSIHs and does not seem to be associated with an increased risk of complications.

Robotic Versus Laparoscopic Surgery for Rectal Cancer: A Comprehensive Review of Oncological Outcomes.

The treatment of rectal cancer is complex and involves specialized multidisciplinary care, although the tenet is still rooted in a high-quality total mesorectal excision. The robotic platform is one of many tools in the arsenal to assist dissection in the low pelvis. This article is a comprehensive review of the oncological outcome comparing robotic vs laparoscopic rectal cancer resection, with a particular focus on total mesorectal excision. There is no statistical difference in total mesorectal grade, circumferential margin, distal margin, and lymph node harvest. Survival data are less mature, but there is also no difference in disease-free or overall survival between the two techniques. Although additional randomized trials are still needed to validate these findings, both techniques are currently acceptable in the minimally invasive treatment of rectal cancer, and surgeon preference is paramount to safe and optimal resection.

A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery.

BACKGROUND: Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness. METHODS: This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality. RESULTS: A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9%, p < 0.06; rectum 7.8 vs. 21.2%, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95% CI 3.63-4.40) was significantly shorter compared to laparoscopic (4.41 days, 95% CI 4.17-4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95% CI 4.13-4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups. CONCLUSIONS: When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.

Robotic-laparoscopic rectal cancer excision versus traditional laparoscopy.

BACKGROUND AND OBJECTIVES: Robotic surgery has been advocated for the radical excision of rectal cancer. Most data supporting its use have been reported from European and Asian centers, with a paucity of data from the United States documenting clear advantages of the robotic technique. This study compares the short-term outcome of robotic versus laparoscopic surgery. METHODS: Consecutive patients who underwent laparoscopic (group 1) or robotic (group 2) rectal cancer excision at a single institution over a 2-year period were retrospectively reviewed. The main outcome measures were operative time, blood loss, conversion rates, number of lymph nodes, margin positivity, length of hospital stay, complications, and readmission rates. RESULTS: Forty-two patients were analyzed. The median operative time was shorter in group 1 than that in group 2 (240 minutes vs 260 minutes, P=.04). No difference was noted in blood loss, transfusion rates, intraoperative complications, or conversion rates. There was no difference in circumferential or distal margin positivity. The median length of stay was shorter in group 1 (5 days vs 6 days, P=.05). The 90-day complication rate was similar in both groups (33% vs 43%, P=.75), but there was a trend toward more anastomotic leaks in group 1 (14% vs 0%, P=.23). Similarly, a non-statistically significant trend toward a higher readmission rate was noted in group 1 (24% vs 5%, P=.18). CONCLUSION: Robotic rectal cancer excision yielded a longer operative time and hospital length of stay, although immediate oncologic results were comparable. The need for randomized data is critical to determine whether the added resource utilization in robotic surgery is justifiable.

Perforation following colorectal endoscopy: what happens beyond the endoscopy suite?

BACKGROUND: The risk factors for perforation from colorectal endoscopy have been well studied, but little is known about clinical outcomes beyond the immediate event. OBJECTIVE: To evaluate short- and long-term outcomes of iatrogenic colorectal perforation following colorectal endoscopy. DESIGN: Retrospective review over 16 years at a single tertiary care institution. MAIN OUTCOME MEASURES: Treatment interventions, morbidity and mortality rates, hospital length of stay, stoma closure rate, and long-term complications. RESULTS: Of 132,259 colorectal endoscopies, 26 patients (0.02%) had a perforation (54% males; mean age, 67 years). The rectosigmoid colon was the most common site of perforation (65%). Thirty-eight percent of the perforations were recognized at the time of procedure, 31% presented within 24 hours, and 31% presented beyond 24 hours. Operative repair was undertaken in 85% of the patients, and 15% were managed with inpatient hospital observation. Primary repair was performed in 68% (defunctioning stoma in 18%). Mean hospital length of stay was 10.1 days. The overall postoperative complications rate was 55%, and wound complications were noted in 45%. The 30-day mortality rate was 19%. No death was observed beyond the first month. American Society of Anesthesiologists physical status Classes 3 and 4 were associated with mortality (p = 0.004). Of 7 patients who received a stoma, only 2 patients (29%) had stoma reversal. Long-term complications included incisional hernia (10%) and small-bowel obstruction (5%). CONCLUSIONS: Perforation following colorectal endoscopy was uncommon in this study but was associated with significant morbidity and mortality. An increased risk of death was noted with higher American Society of Anesthesiologists physical status class.

Successful salvage of late failure of hepatic portocholecystostomy (gallbladder Kasai) with Roux-en-Y cholecystojejunostomy.

The hepatic portoenterostomy (HPE) is the accepted initial operation for biliary reconstruction for biliary atresia, but in a select group of patients with patent distal extrahepatic bile ducts (PDEBD), a hepatic portocholecystostomy (HPC) may also be considered. A10 year old boy presented with sudden onset of jaundice following a successful HPC at 2 months of age. Radiographic evaluation revealed excretion into a distended gallbladder with distal biliary obstruction. He underwent a successful Roux-en-Y cholecystojejunostomy and remains jaundice-free two years later. Cholecystojejunostomy is an effective salvage operation for patients who develop late distal biliary obstruction after an HPC.

Radiofrequency treatment for fecal incontinence: is it effective long-term?

OBJECTIVE: The aim of this study was to evaluate the short- and long-term outcome of the radiofrequency treatment for moderate to severe fecal incontinence. DESIGN: This study is a retrospective review of a single-institution experience. PATIENTS: Patients who underwent the radiofrequency procedure were included. MAIN OUTCOME MEASURES: The primary outcomes measured were the complication rate, short- and long-term response, and the rate of subsequent intervention for incontinence. RESULTS: Twenty-seven patients underwent 31 radiofrequency procedures (81% women; mean age, 64 years). Median length of symptoms was 3 years. Biofeedback had failed for 52% of patients, and 23% of patients had previous surgical intervention. Thirty-eight percent of patients had a sphincter defect. Minor complications were observed in 19% of the patients. A treatment response was noted in 78% of the patients (mean Cleveland Clinic Florida Fecal Incontinence Score: 16 (baseline) and 10.9 (3 months postoperatively)). However, a sustained long-term response without any additional intervention was noted in 22% of the patients, and 52% of the patients underwent or are awaiting additional intervention for persistent or recurrent incontinence (mean follow-up, 40 months). LIMITATION: This study is limited by its retrospective nature and the limited number of subjects. CONCLUSIONS: The radiofrequency procedure was safe, but a long-term benefit was noted in a minority of patients with moderate to severe fecal incontinence. Additional interventions were required in more than half of the patients. Larger studies are needed to determine the impact of various patient-related factors on the outcome of the radiofrequency treatment to identify the ideal patient for this therapy.

Defunctioning loop ileostomy for pelvic anastomoses: predictors of morbidity and nonclosure.

OBJECTIVE: The aim of this study was to determine the morbidity of a defunctioning loop ileostomy and the subsequent closure rate, and to identify the predictors of complications and nonclosure of stoma. DESIGN: This study is a retrospective review of a single-institution experience. PATIENTS: All patients who underwent a planned temporary defunctioning loop ileostomy performed synchronously with a pelvic anastomosis during a 6-year period were included. MAIN OUTCOME MEASURES: The primary outcome measures were the ileostomy complication rate for the entire spectrum of care, readmission and reoperation rates to treat ileostomy complications, and subsequent closure rate. Patient and treatment factors were evaluated for their independent effect on complications and closure rate with the use of multivariable logistic regression. RESULTS: One hundred twenty-three patients were identified (median age, 51 years). Of these patients, 64.2% developed ≥1 minor or major ileostomy complications (13.8% during index hospitalization, 52.8% as outpatient, and 23.4% after closure). Readmitted for dehydration following ileostomy formation were 11.4% of patients. The ileostomy was closed in 76.4% of patients with 8.6% requiring a midline laparotomy. The overall ileostomy-related reoperation rate was 10.4% (2.4% during index hospitalization, 1.6% at readmission, and 6.4% following ileostomy closure). Obesity (BMI ≥30 kg/m) was associated with a higher overall ileostomy complication rate (OR 8.56, 95% CI 1.64-44.74) and outpatient complication rate (OR 7.69, 95% CI 2.48-23.81). Age >65 years (OR 53.34, 95% CI 4.21-676.14) and hypertension (OR 8.36, 95% CI 1.09-64.43) increased the risks of high ileostomy output and dehydration. Obesity (OR 4.61, 95% CI 1.14-18.54) and smoking (4.47, 95% CI 1.43-13.98) decreased the likelihood of ileostomy closure. LIMITATION: This study was limited by its retrospective nature. CONCLUSIONS: The morbidity of a defunctioning loop ileostomy remains significant. Obesity is an independent predictor of ileostomy complications. Older age and hypertension increase the risks of high-output stoma and dehydration. Almost one quarter of patients never have the ileostomy closed. Obesity and smoking are associated with less likelihood of a subsequent ileostomy closure.

Effect of angiotensin AT1 receptor antagonist on D-galactosamine-induced acute liver injury.

1. Acute liver injury is a severe disease in which metabolic homeostasis is affected. The presence of liver cell death triggers a cascade of inflammatory responses leading to various degrees of liver damage. The pathophysiology of liver injury is complex, involving an interplay between parenchymal and non-parenchymal cells. 2. There is increasing evidence for a role of the local renin-angiotensin system (RAS) in liver cell death, inflammatory response and liver regeneration. It has been shown that the local RAS plays an important regulatory role in a variety of tissues. In experimental hepatic fibrogenesis, the angiotensin AT(1) receptor (AT(1)R) blocker losartan has been shown to be able to attenuate transforming growth factor-b1 activity and collagen gene expression. 3. In the present study, using a D-galactosamine (GalN)-induced liver failure rat, AT(1)R were localized around the centrilobular region, which was not evident in normal liver. Blood tests showed an elevation of total bilirubin and alanine aminotransferase. Furthermore, there was an increase in tissue-specific inhibitor of metalloproteinase (TIMP)-1 protein in the liver. Losartan treatment was able to reduce all these parameters. Levels of TIMP-1 protein were reduced by 1.5- and 1.56-fold on Days 1 and 3, respectively (both P < 0.05), in the losartan-treated group relative to the GalN-treated group. The survival rate of the losartan-treated group was significantly higher than that of the GalN-treated group (5 day survival 85 vs 42.5%, respectively; P < 0.05). 4. In conclusion, the AT(1)R blocker losartan suppresses GalN-induced liver injury. This may indicate that AT(1)R blockers may have therapeutic potential in the treatment of acute liver injury.

Renin-angiotensin system in the carotid body.

Research studies have been done on the influence of the renin-angiotensin system (RAS) on numerous tissues and organs. The local RAS, which is frequently of paracrine/autocrine origin, caters to specific organ and tissue needs through actions that add to, or differ from, the circulating RAS. Recent data have demonstrated a functional expression of RAS in the carotid body, wherein the carotid chemoreceptors play a major physiological role in the regulation of autonomic responses to changes in arterial chemical content. However, the angiotensin II and other vasoactive substances can directly modulate the excitability of the chemoreceptor. Long-term hypoxia modifies the level of gene expression in the carotid body by increasing the expression of AT(1) receptors along with sensitivity of the chemoreceptor to angiotensin II. Even though these findings support a physiological role of RAS in the carotid body, it has yet to be clearly defined. As a result this review will present current information about expression and localization of AT(1) receptors, and show that local RAS exists in the carotid body. The regulation of RAS by chronic hypoxia, the significance of its changes and clinical relevance in the carotid body, are also addressed.