Publications by authors named "Steven D Wexner"

322 Publications

Clinical Factors Contributing to Anastomotic Leak After Mid-to-High Colorectal Anastomosis.

Am Surg 2021 Sep 14:31348211041555. Epub 2021 Sep 14.

Department of Colorectal Surgery, 219819Cleveland Clinic Florida, Weston, FL, USA.

Background: Low colorectal anastomoses carry a high anastomotic leak (AL) rate (up to 20%) and thus are commonly diverted. Much less is known about mid-to-high colorectal anastomosis, which carries a leak rate of 2-4%. The objective of this study was to determine our AL rate after mid-to-high colorectal anastomosis and associated risk factors.

Methods: A single center retrospective cohort study of patients undergoing left colonic resections with mid-to-high colorectal anastomosis (≥7 cm from the anal verge) from January 2008 to October 2017 was utilized. Main outcome, AL, defined as clinical suspicion supported by radiological or intraoperative findings, was calculated and risk factors assessed using multivariable logistic regression analysis.

Results: 977 patients were included; 487 (49.9%) were male, with a mean age of 59.8 (+/-12.1) years. Mean BMI was 27.5 (+/-5.5) kg/m. Diverticular disease (67.5%), malignancy (17.4%), and inflammatory bowel disease (2.2%) were the main indications for resection. Mean length of stay was 6.7 (+/-4.5) days. 455 (46.8%) colonic resections were performed by laparoscopy, 283 (29.1%) by hand assisted surgery, 219 (22.5%) by laparotomy, and 16 (1.6%) by robotics. Majority of patients had complete donuts (99.6%) and a negative air leak test (97.7%). 149 patients (15.3%) underwent construction of a diverting stoma. The overall AL rate was 2.1% (n = 20). Increased BMI (>30 kg/m), = .02, was an independent risk factor for AL and a trend observed for positive air leak tests ( = .05), with other factors failing to achieve statistical significance.

Conclusions: Patients with mid-to-high colorectal anastomosis have a 2% AL risk. Increased BMI was a risk factor for AL.
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http://dx.doi.org/10.1177/00031348211041555DOI Listing
September 2021

An enlarging ischiorectal mass.

Surgery 2021 Sep 2;170(3):e9-e10. Epub 2021 Apr 2.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL. Electronic address:

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http://dx.doi.org/10.1016/j.surg.2021.02.059DOI Listing
September 2021

A Note from the Editors-in-Chief.

Surgery 2021 Sep;170(3):649

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http://dx.doi.org/10.1016/j.surg.2021.07.024DOI Listing
September 2021

Elective minimally invasive surgery for sigmoid diverticulitis: operative outcomes of patients with complicated versus uncomplicated disease.

Colorectal Dis 2021 Jul 26. Epub 2021 Jul 26.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA.

Aim: The aim of this work was to compare the results of elective minimally invasive surgery between patients with complicated sigmoid diverticulitis and those with uncomplicated disease.

Method: An institutional review board-approved database was searched for all consecutive patients who underwent elective minimally invasive surgery, including laparoscopic, hand-assisted and robotic sigmoidectomy, for diverticulitis between 2010 and 2017; they were classified according to the modified Hinchey classification as having complicated (abscess, fistula, stricture, obstruction, bleeding or previous perforation) versus uncomplicated disease. Data recorded included baseline demographics, indications for surgery, operative details and complications.

Results: Three hundred and twenty-five patients underwent elective sigmoidectomy for complicated (n = 105) and uncomplicated (n = 220) diverticulitis. Surgical indications for complicated disease were abscess (n = 74), stricture (n = 14), fistula (n = 28) and bleeding (n = 7). The two groups were statistically comparable for age, gender, body mass index and American Society of Anesthesiologists score. Patients with complicated disease had higher rates of concomitant loop ileostomy creation (9.5% vs. 0.9%, p < 0.001) and synchronous resections (9.5% vs. 2.7%, p = 0.01), higher volumes of blood loss (177 ± 140 vs. 125 ± 92 ml, p < 0.001), longer length of stay (5.6 ± 3 vs. 4.8 ± 2 days, p = 0.04) and longer operating time (218.2 ± 59 vs. 185.8 ± 63 min, p < 0.001). There were no significant differences in anastomotic leakage (3% vs. 1%, p = 0.3), conversion to laparotomy (4.8% vs. 2.3%, p = 0.3) or overall complications (36% vs. 25.9%, p = 0.06) for complicated versus uncomplicated disease, respectively.

Conclusion: Minimally invasive surgery for complicated diverticulitis resulted in higher rates of construction of proximal ileostomy and synchronous resections and longer operating times and length of hospital stay. Otherwise, it has outcomes that are not significantly different from the results recorded in patients with uncomplicated disease.
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http://dx.doi.org/10.1111/codi.15837DOI Listing
July 2021

High-Intensity vs Low-Intensity Knowledge Translation and Performance Metrics in Patients With Rectal Cancer.

Authors:
Steven D Wexner

JAMA Netw Open 2021 Jul 1;4(7):e2119393. Epub 2021 Jul 1.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.19393DOI Listing
July 2021

A systematic review and meta-analysis of the outcome of ileal pouch anal anastomosis in patients with obesity.

Surgery 2021 Jul 2. Epub 2021 Jul 2.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL. Electronic address: https://twitter.com/SWexner.

Background: Ileal-pouch anal anastomosis is used for treatment of different conditions, including mucosal ulcerative colitis and familial adenomatous polyposis. The present systematic review aimed to assess the literature for studies that compared the outcome of ileal-pouch anal anastomosis in patients with obesity versus patients with ideal weight.

Methods: A systematic literature search of electronic databases including PubMed, Scopus, Web of Science, and Cochrane library was performed and reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The main outcome measures were pouch failure, pouch complications, overall complications, operation time, blood loss, and hospital stay.

Results: This systematic review included 6 retrospective studies (3,460 patients). Out of the total number of patients, 19.8% had obesity or overweight. Patients with obesity were significantly less likely to have laparoscopic ileal-pouch anal anastomosis compared with patients with ideal body mass index (odds ratio = 0.436; P = .017). The weighted mean operation time and blood loss were significantly longer in the obesity group than the ideal weight group (weighted mean difference = 22.84; P = .006) and (weighted mean difference = 85.8; P < .001). The obesity group was associated with significantly higher odds of total complications (odds ratio = 2.27; P < .001), leak (odds ratio = 1.81; P = .036), and incisional hernia (odds ratio = 4.56; P < .001). The 2 groups had comparable rates of pouch failure, pouchitis, stricture, pelvic sepsis, wound infection, bowel obstruction, ileus, and venous thromboembolism. Male sex, longer operation time, and including inflammatory bowel disease patients only were significantly associated with higher complications in the obesity group.

Conclusion: Patients with obesity who undergo ileal-pouch anal anastomosis are more likely to have laparotomy rather than a laparoscopic procedure, have longer operation time, greater blood loss, higher overall complications, leak and incisional hernia, and longer hospital stay.
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http://dx.doi.org/10.1016/j.surg.2021.06.009DOI Listing
July 2021

Perineal reconstruction after extralevator abdominoperineal resection: Differences among minimally invasive, open, or open with a vertical rectus abdominis myocutaneous flap approaches.

Surgery 2021 Jun 16. Epub 2021 Jun 16.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL. Electronic address:

Background: Perineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared short- and long-term results of laparoscopic abdominoperineal resection with open surgery ± vertical rectus abdominis myocutaneous flap.

Methods: This is a single-institution retrospective observational study of 204 consecutive patients with advanced low rectal cancer who underwent extralevator abdominoperineal resection from January 2010 to August 2020. Main outcome measures were short-term results, wound complications, and incisional, parastomal, and perineal hernia rates.

Results: Fifty-five (27%) patients had a laparoscopic approach, 80 (39%) open, and 69 (33%) open + vertical rectus abdominis myocutaneous flap. The groups had similar median length of follow up (P = .75). Patients' age and radiation, intraoperative and postoperative complications, mortality, and readmission rates were similar among the 3 groups. Perineal wound infection and dehiscence rates were not influenced by surgical approach. Laparoscopy resulted in higher perineal (7.3 vs 2.5 vs 0%; P = .047) and parastomal (23.6 vs 13.8 vs 5.8%; P = .016) hernia rates than did open or open + vertical rectus abdominis myocutaneous flap. Patients who underwent an open approach had a higher body mass index and rate of prior surgeries and preoperative ostomies. Laparoscopic and open approaches had significantly shorter operative times (300 vs 303 vs 404 minutes, respectively; P < .001) and shorter length of stay (7.6 vs 10.8 vs 11.12, respectively; P = .006) compared to open with a flap approach.

Conclusion: Open and open + vertical rectus abdominis myocutaneous flap approaches for reconstruction after abdominoperineal resection had lower parastomal and perineal hernias rates but similar postoperative morbidity as did the laparoscopic approach.
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http://dx.doi.org/10.1016/j.surg.2021.05.027DOI Listing
June 2021

Patients Undergoing Ileoanal Pouch Surgery Experience a Constellation of Symptoms and Consequences Representing a Unique Syndrome: A Report from the Patient-Reported Outcomes After Pouch Surgery (PROPS) Delphi Consensus Study.

Dis Colon Rectum 2021 07;64(7):861-870

Massachusetts General Hospital Colorectal Surgery and Crohn's Colitis Centers, Department of Gastrointestinal Surgery and Surgical Oncology, Boston, Massachusetts.

Background: Functional outcomes after ileoanal pouch creation have been studied; however, there is great variability in how relevant outcomes are defined and reported. More importantly, the perspective of patients has not been represented in deciding which outcomes should be the focus of research.

Objective: The primary aim was to create a patient-centered definition of core symptoms that should be included in future studies of pouch function.

Design: This was a Delphi consensus study.

Setting: Three rounds of surveys were used to select high-priority items. Survey voting was followed by a series of online patient consultation meetings used to clarify voting trends. A final online consensus meeting with representation from all 3 expert panels was held to finalize a consensus statement.

Patients: Expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients, including patients, colorectal surgeons, and gastroenterologists or other clinicians.

Main Outcome Measures: A consensus statement was the main outcome.

Results: patients, 62 colorectal surgeons, and 48 gastroenterologists or nurse specialists completed all 3 Delphi rounds. Fifty-three patients participated in online focus groups. One hundred sixty-one stakeholders participated in the final consensus meeting. On conclusion of the consensus meeting, 7 bowel symptoms and 7 consequences of undergoing ileoanal pouch surgery were included in the final consensus statement.

Limitations: The study was limited by online recruitment bias.

Conclusions: This study is the first to identify key functional outcomes after pouch surgery with direct input from a large panel of ileoanal pouch patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function. See Video Abstract at http://links.lww.com/DCR/B571.

Los Pacientes Sometidos A Ciruga De Reservorio Ileoanal Experimentan Una Constelacin De Sntomas Y Consecuencias Que Representan Un Sndrome Unico: Un Informe de los Resultados Reportados por los Pacientes Posterior a la Cirugía de Reservorio (PROPS) Estudio de Consenso DelphiANTECEDENTES:Los resultados funcionales después de la creación del reservorio ileoanal han sido estudiados; sin embargo, existe una gran variabilidad en la forma en que se definen y reportan los resultados relevantes. Más importante aún, la perspectiva de los pacientes no se ha representado a la hora de decidir qué resultados deberían ser el foco de investigación.OBJETIVO:El objetivo principal era crear en el paciente una definición centrada de los síntomas principales que debería incluirse en los estudios futuros de la función del reservorio.DISEÑO:Estudio de consenso Delphi.ENTORNO CLINICO:Se emplearon tres rondas de encuestas para seleccionar elementos de alta prioridad. La votación de la encuesta fue seguida por una serie de reuniones de consulta de pacientes en línea que se utilizan para aclarar las tendencias de votación. Se realizo una reunión de consenso final en línea con representación de los tres paneles de expertos para finalizar una declaración de consenso.PACIENTES:Se eligieron partes interesadas expertas para correlacionar con el escenario clínico del equipo multidisciplinario que atiende a los pacientes con reservorio: pacientes, cirujanos colorrectales, gastroenterólogos / otros médicos.PRINCIPALES MEDIDAS DE VALORACION:Declaración de consenso.RESULTADOS:Ciento noventa y cinco pacientes, 62 cirujanos colorrectales y 48 gastroenterólogos / enfermeras especialistas completaron las tres rondas Delphi. 53 pacientes participaron en grupos focales en línea. 161 interesados participaron en la reunión de consenso final. Al concluir la reunión de consenso, siete síntomas intestinales y siete consecuencias de someterse a una cirugía de reservorio ileoanal se incluyeron en la declaración de consenso final.LIMITACIONES:Sesgo de reclutamiento en línea.CONCLUSIONES:Este estudio es el primero en identificar resultados funcionales claves después de la cirugía de reservorio con información directa de un gran panel de pacientes con reservorio ileoanal. La inclusión de pacientes en todas las etapas del proceso de consenso permitió un verdadero enfoque centrado en el paciente para definir los dominios principales en los que debería centrarse los estudios futuros de la función del reservorio. Consulte Video Resumen en http://links.lww.com/DCR/B571.
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http://dx.doi.org/10.1097/DCR.0000000000002099DOI Listing
July 2021

Introduction to socially conscious surgical care and research.

Surgery 2021 06 21;169(6):1267. Epub 2021 Apr 21.

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http://dx.doi.org/10.1016/j.surg.2021.02.046DOI Listing
June 2021

Karydakis procedure versus Limberg flap for treatment of pilonidal sinus: an updated meta-analysis of randomized controlled trials.

Int J Colorectal Dis 2021 Jul 10;36(7):1421-1431. Epub 2021 Apr 10.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.

Background: The Karydakis procedure (KP) and Limberg flap (LF) are two commonly performed operations for pilonidal sinus disease (PND). The present meta-analysis aimed to review the outcome of randomized trials that compared KP and LF.

Methods: Electronic databases were searched in a systematic manner for randomized trials comparing KP and LF through July 2020. This meta-analysis was reported in line with the PRISMA statement. The main outcome measures were failure of healing of PND, complications, time to healing, time to return to work, and cosmetic satisfaction.

Results: Fifteen randomized controlled trials (1943 patients) were included. KP had a significantly shorter operation time than LF with a weighted mean difference (WMD) of -0.788 (95%CI: -11.55 to -4.21, p < 0.0001). Pain scores, hospital stay, and time to healing were similar. There was no significant difference in overall complications (OR= 1.61, 95%CI: 0.9-2.85, p = 0.11) and failure of healing (OR= 1.22, 95%CI: 0.76-1.95, p = 0.41). KP had higher odds of wound infection (OR= 1.87, 95%CI: 1.15-3.04, p = 0.011) and seroma formation (OR= 2.33, 95%CI: 1.39-3.9, p = 0.001). KP was followed by a shorter time to return to work (WMD= -0.182; 95%CI: -3.58 to -0.066, p = 0.04) and a higher satisfaction score than LF (WMD= 2.81, 95%CI: 0.65-3.77, p = 0.01).

Conclusions: KP and LF were followed by similar rates of complications and failure of healing of PND and comparable stay, pain scores, and time to wound healing. KP was associated with higher rates of seroma and wound infection, shorter time to return to work, and higher cosmetic satisfaction than LF.
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http://dx.doi.org/10.1007/s00384-021-03922-wDOI Listing
July 2021

Gracilis Muscle Interposition for Treatment of Complex Anal Fistula: Experience With 119 Consecutive Patients.

Dis Colon Rectum 2021 07;64(7):881-887

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida.

Background: Treatment of complex anal fistula is challenging, often mandating multiple procedures. The gracilis muscle has been used to treat perineal fistulas and to repair perineal defects.

Objective: This study aims to report the results of gracilis muscle interposition for complex anal fistula, including prognostic factors for success.

Design: This is a retrospective analysis of a prospective database for patients who underwent gracilis muscle interposition for complex anal fistula from 2000 to 2018.

Setting: Patient demographics, operative data, and postoperative outcome were obtained from medical records. Office visits were used for follow-up.

Patients: All patients who underwent gracilis muscle interposition for complex anal fistula were included. Patients who underwent gracilis muscle interposition for reasons other than complex anal fistula were excluded.

Main Outcome Measures: The primary outcome measured was the healing of complex anal fistula following gracilis muscle interposition and following additional procedures, when needed.

Results: A total of 119 patients (60 men, 59 women; median age: 56 (21-85) years) were included. The initial success rate of gracilis muscle interposition was 42%; the final success rate if additional procedures were undertaken was 92%. Overall success rate was 32.2% in women and 51.6% in men. Univariate analysis revealed that sex (p = 0.0315) and bed rest >3 days (p = 0.0078) were significant poor prognostic factors for failure, whereas the multivariate logistic regression model showed that length of bed rest >3 days was a significant poor prognostic factor for failure. In the female subgroup, multivariate analysis showed that bed rest ≥3 days was a significant poor prognostic factor, whereas in the male population there was no significant prognostic factor.

Limitation: This study was limited by its retrospective nature and the heterogeneity of patients.

Conclusion: Although initial success is <50%, the ultimate success after gracilis muscle interposition and other subsequent procedures is >90%. Patients must be preoperatively counseled that additional procedures will probably be required to achieve successful fistula closure. Furthermore, prolonged bed rest should be avoided after gracilis muscle interposition. See Video Abstract at http://links.lww.com/DCR/B551.

Interposicin Del Msculo Gracilis Para El Tratamiento De La Fstula Anal Compleja Experiencia Con Pacientes Consecutivos: ANTECEDENTES:El tratamiento de la fístula anal compleja es un desafío que a menudo requiere de múltiples procedimientos quirúrgicos. El músculo gracilis se ha utilizado para tratar fístulas y reparar defectos perineales.OBJETIVO:Informar los resultados de la interposición del músculo gracilis para la fístula anal compleja, incluyendo los factores pronósticos para un tratamiento exitoso.DISEÑO:Se efectuó un análisis retrospectivo obtenido de una base de datos prospectiva para pacientes sometidos a interposición del músculo gracilis por fístula anal compleja del 2000 al 2018.METODO:Los datos demográficos de los pacientes, la información del procedimiento quirúrgico y los resultados postoperatorios se obtuvieron de los expedientes clínicos; el seguimiento se llevó a cabo por medio de visitas al consultorio.PACIENTES:Se incluyeron todos los pacientes sometidos a interposición del músculo gracilis por fístula anal compleja; Se excluyeron los pacientes que se sometieron a interposición del músculo gracilis por motivos distintos a la fístula anal compleja.CRITERIOS DE EVALUACION DE LOS RESULTADOS:Curación de una fístula anal compleja después de la interposición del músculo gracilis y procedimientos adicionales, cuando fueron necesarios.RESULTADOS:Se estudiaron un total de 119 pacientes [60 hombres, 59 mujeres; con media de edad de 56 (21-85) años]. La tasa de éxito inicial de la interposición del músculo gracilis fue del 42%; La tasa de éxito final cuando realizaron procedimientos adicionales fue del 92%. La tasa de éxito global fue del 32,2% en mujeres y del 51,6% en hombres. El análisis univariado reveló que el género (p = 0,0315) y el reposo en cama > 3 días (p = 0,0078) en forma significativa fueron factores de pronóstico bajo para el fracaso, mientras que el modelo de regresión logística multivariable mostró que la duración del reposo en cama> 3 días fue un factor de pronóstico significativamente bajo para fracaso. En el subgrupo de mujeres, el análisis multivariado mostró que el reposo en cama ≥3 días fue un factor de pronóstico significativamente bajo, mientras que en la población masculina no hubo un factor pronóstico significativo.LIMITACIÓN:Carácter retrospectivo y heterogenicidad de los pacientes.CONCLUSIÓN:Aunque el éxito inicial es <50%, el éxito final después de la interposición del músculo gracilis y otros procedimientos posteriores es > 90%. Se debe aconsejar a los pacientes antes de la operación que probablemente se requieran procedimientos adicionales para lograr el cierre exitoso de la fístula. Además, debe evitarse el reposo prolongado en cama después de la interposición del músculo gracilis. Consulte Video Resumen en http://links.lww.com/DCR/B551.
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http://dx.doi.org/10.1097/DCR.0000000000001964DOI Listing
July 2021

Artificial intelligence: Not an oxymoron in surgery.

Surgery 2021 04 21;169(4):749. Epub 2020 Oct 21.

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http://dx.doi.org/10.1016/j.surg.2020.09.030DOI Listing
April 2021

The significant interaction between age and diabetes mellitus for colorectal cancer: Evidence from NHANES data 1999-2016.

Prim Care Diabetes 2021 06 2;15(3):518-521. Epub 2021 Mar 2.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA. Electronic address:

Background: Diabetes mellitus has been associated with elevated risk of colorectal cancer (CRC), although interaction between age and DM is unclear. We examined the relationship among DM, CRC and age.

Methods: 22,580 subjects aged ≥18 years were identified from the National Health and Nutrition Examination Survey (NHANES) database collected between 1999-2016. To account for the complex, stratified, multistage probability sampling design in NHANES, SASv9.4 Procedure Survey Methodology was applied. Univariate analysis compared individual baseline characteristics between subjects with and without DM. Multivariate logistic regression model assessed association between DM and CRC, in which the model included factors with p<0.05 in univariate analysis as covariates.

Results: Univariate analysis showed significant differences in age (p<0.0001), race (p<0.0001), smoking (p=0.0023) and body mass index (p<0.0001) between No-DM and DM. Multivariate analysis revealed significant interaction between age and DM (p=0.0004). Subjects with DM aged 18-65 were more likely to experience CRC (OR=4.47, 95%CI=(1.33-15.07); p=0.0157) compared to those without DM. Subjects with DM aged >65 were not at increased risk for CRC (OR=0.83, 95%CI=(0.43-1.59); p=0.5665) compared to those without DM.

Conclusions: Age, DM, and interaction between age and DM are risk factors for CRC. Individuals with DM aged 18-65 years have a higher CRC risk.
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http://dx.doi.org/10.1016/j.pcd.2021.02.006DOI Listing
June 2021

Impact of BMI on Adverse Events After Laparoscopic and Open Surgery for Rectal Cancer.

J Gastrointest Cancer 2021 Mar 3. Epub 2021 Mar 3.

Division of Surgical Oncology and General Surgery, University Health Network and Princess Margaret Hospital, 399 Bathurst St., ON, M5T2S8, Toronto, USA.

Purpose: The impact of body mass index (BMI) on outcomes after open or laparoscopic surgery for rectal cancer remains unclear. The objective of this retrospective cohort study was to examine the interaction of body mass index and surgical modality (i.e., laparoscopy versus open) with respect to short-term clinical outcomes in patients with rectal cancer.

Methods: The ACS-NSQIP database (2012-2016) was reviewed for patients undergoing open or laparoscopic surgery for rectal cancer. The primary outcome was 30-day all-cause morbidity. Logistic regression and Cox proportional hazard models were used for analysis.

Results: A total of 16,145 patients were grouped into open (N = 6759, 42%) and laparoscopic (N  = 9386, 58%) cohorts. Patients with higher BMI (p < 0.001) and those undergoing open surgery (p < 0.001) were at increased risk of all-cause morbidity. There was no significant change in the odds ratio of experiencing all-cause morbidity between open and laparoscopic surgery with increasing BMI (p = 0.572). Median length of stay was significantly shorter in the laparoscopy group (4 days vs. 6 days; p < 0.001), at the cost of increased operative time (239 min vs. 210 min, p < 0.001). The difference in operative time between laparoscopy and open surgery did not increase with rising BMI (i.e., ∆37 min vs. ∆39 min at BMI 25 kg/m vs 50 kg/m, respectively, p = 0.491).

Conclusion: BMI may not be a strong modifier for surgical approach with respect to short-term clinical outcomes in patients with obesity and rectal cancer. Laparoscopic surgery was associated with improved short-term clinical outcomes, without much change in the absolute difference in operative time compared with open surgery, even at higher BMIs.
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http://dx.doi.org/10.1007/s12029-021-00612-2DOI Listing
March 2021

International Delphi Expert Consensus on Safe Return to Surgical and Endoscopic Practice: From the Coronavirus Global Surgical Collaborative.

Ann Surg 2021 07;274(1):50-56

Southern Illinois University School of Medicine, Departments of Surgery and Medical Education, Springfield, Illinois.

Objective: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities.

Background: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers.

Methods: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting.

Results: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements.

Conclusions: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.
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http://dx.doi.org/10.1097/SLA.0000000000004674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189258PMC
July 2021

NEW FEATURES IN SURGERY.

Surgery 2021 04 16;169(4):707. Epub 2021 Feb 16.

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http://dx.doi.org/10.1016/j.surg.2021.01.001DOI Listing
April 2021

Strengths and weaknesses in the methodology of survey-based research in surgery: A call for standardization.

Surgery 2021 08 16;170(2):493-498. Epub 2021 Feb 16.

Faculty of Medicine, University of Toronto, Canada; Department of Surgery, University Health Network, Toronto, Canada; Princess Margaret Cancer Centre, Toronto, Canada. Electronic address:

Background: Survey-based studies are often the basis of policy changes; however, the methodologic quality of such research can be questionable. Methodologic reviews of survey-based studies have been conducted in other medical fields, but the surgical literature has not been assessed.

Methods: All citations published in 9 major surgical journals from 2002 to 2019 were screened for studies administering surveys to health care professionals. Descriptive and methodologic data were collected by 2 reviewers who also assessed the transparency and quality of the methodology. Agreement between reviewers was assessed using a weighted κ-statistic. Survey quality metrics were measured, descriptive statistics were calculated, and regression analysis was used to assess the association between subjective overall study quality and objective quality metrics.

Results: We included 271 articles in our analysis; the weighted-κ for reviewer quality assessment was 0.69 and for transparency assessment was 0.71. Deficiencies were identified in questionnaire development methodology and reporting, in which the median number of developmental steps reported was 1 (of 8) and in the reporting of incomplete/missing data where 63% of studies failed to report how incomplete questionnaires were managed; 70% of studies failed to report missing data. Overall subjective quality was positively associated with objective quality metrics.

Conclusion: The deficiencies identified in the surgical literature highlight the need for improvement in the conduct and reporting of survey-based research, both in the surgical literature and more broadly. Adoption of a standardized reporting guideline for survey-based research may ameliorate the deficiencies identified by this study and other investigations.
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http://dx.doi.org/10.1016/j.surg.2021.01.006DOI Listing
August 2021

Can normalized carcinoembryonic antigen following neoadjuvant chemoradiation predict tumour recurrence after curative resection for locally advanced rectal cancer?

Colorectal Dis 2021 06 25;23(6):1346-1356. Epub 2021 Feb 25.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.

Aim: The aim of this work was to evaluate whether normalized carcinoembryonic antigen (CEA) following neoadjuvant chemoradiation predicts the prognosis following curative resection in locally advanced rectal cancer.

Method: Patients who underwent neoadjuvant chemoradiation and curative resection for locally advanced rectal cancer between 2010 and 2015 were divided into three groups: Group A (n = 119, normal-to-normal): normal CEA before and after neoadjuvant chemoradiation; Group B (n = 37, high-to-normal): elevated CEA before and normal CEA after neoadjuvant chemoradiation; Group C (n = 36, high-to-high): elevated CEA before and after neoadjuvant chemoradiation. Overall and disease-free survival were compared. Univariate and multivariate analyses identified potential predictors for recurrence.

Results: One hundred and ninety two patients [median age 59 years (range 31-87), 65.1% male] were identified: 54.7% had low rectal cancer: 12.5% were clinical stage T4 and 70.3% were clinically node positive; 21.9% achieved complete pathological response; 24.5% had abdominoperineal resection (APR); and 70.3% underwent adjuvant chemotherapy following curative resection. Significantly more patients in Group C underwent APR (p = 0.0209), had advanced pathological T stage (P = 0.0065) and a higher prevalence of perineural invasion (p = 0.0042). Overall and disease-free survival were significantly higher for Group A than for Group C [hazard ratio (HR) = 4.32, 95% CI = 1.66-11.21, p = 0.0026 and HR=2.68, 95% CI = 1.33-5.40, p = 0.0057, respectively]. No significant difference was noted between Groups A and B for overall (p = 0.0591) or disease-free (p = 0.2834) survival. Another risk factor associated with recurrence and death was clinical T4 stage; nodal positivity was a risk factor only for recurrence.

Conclusion: Elevated CEA after neoadjuvant chemoradiation and clinical stage T4 disease were unfavourable predictors for overall and disease-free survival. Normalized CEA during neoadjuvant chemoradiation may serve as a prognosticator, although pretreatment CEA may significantly affect survival.
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http://dx.doi.org/10.1111/codi.15583DOI Listing
June 2021

COVID-19 Testing as a Contributory Cause of Delayed Treatment of a Pyogenic Liver Abscess.

Am Surg 2020 Dec 30:3134820983201. Epub 2020 Dec 30.

Department of Colorectal Surgery, Digestive Disease Institute, 219819Cleveland Clinic Florida, Weston FL, USA.

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http://dx.doi.org/10.1177/0003134820983201DOI Listing
December 2020

DElayed COloRectal cancer care during COVID-19 Pandemic (DECOR-19): Global perspective from an international survey.

Surgery 2021 04 17;169(4):796-807. Epub 2020 Nov 17.

Digestive Disease Institute, Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, FL.

Background: The widespread nature of coronavirus disease 2019 (COVID-19) has been unprecedented. We sought to analyze its global impact with a survey on colorectal cancer care during the pandemic.

Methods: The impact of coronavirus disease 2019 on preoperative assessment, elective surgery, and postoperative management of colorectal cancer patients was explored by a 35-item survey, which was distributed worldwide to members of surgical societies with an interest in colorectal cancer care. Respondents were divided into 2 comparator groups: (1) "delay" group: colorectal cancer care affected by the pandemic and (2) "no delay" group: unaltered colorectal cancer practice.

Results: A total of 1,051 respondents from 84 countries completed the survey. No substantial differences in demographics were found between the delay (745, 70.9%) and no delay (306, 29.1%) groups. Suspension of multidisciplinary team meetings, staff members quarantined or relocated to coronavirus disease 2019 units, units fully dedicated to coronavirus disease 2019 care, and personal protective equipment not readily available were factors significantly associated to delays in endoscopy, radiology, surgery, histopathology, and prolonged chemoradiation therapy-to-surgery intervals. In the delay group, 48.9% of respondents reported a change in the initial surgical plan, and 26.3% reported a shift from elective to urgent operations. Recovery of colorectal cancer care was associated with the status of the outbreak. Practicing in coronavirus disease-free units, no change in operative slots and staff members not relocated to coronavirus disease 2019 units were statistically associated with unaltered colorectal cancer care in the no delay group, while the geographic distribution was not.

Conclusion: Global changes in diagnostic and therapeutic colorectal cancer practices were evident. Changes were associated with differences in health care delivery systems, hospital's preparedness, resource availability, and local coronavirus disease 2019 prevalence rather than geographic factors. Strategic planning is required to optimize colorectal cancer care.
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http://dx.doi.org/10.1016/j.surg.2020.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670903PMC
April 2021

Editors' introduction.

Surgery 2021 05 27;169(5):1018. Epub 2020 Nov 27.

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http://dx.doi.org/10.1016/j.surg.2020.11.001DOI Listing
May 2021

Exploring the perioperative outcomes of a sample of successful adopters of transanal total mesorectal excision (taTME) during the learning phase.

Surgery 2021 04 24;169(4):774-781. Epub 2020 Nov 24.

Department of Surgery, Cleveland Clinic, Weston, FL.

Background: Transanal total mesorectal excision can be a technically challenging operation to master. While many early adopters have reported adequate outcomes, others have failed to reproduce these results. There are contradicting data on oncologic outcomes during the learning phase of this technique. Thus, our objective was to perform a multicentered assessment of oncological outcomes in patients undergoing transanal total mesorectal excision during the learning phase in a sample of successful adopting centers.

Methods: Surgeons from 8 centers with experience in the management of rectal cancer were invited to participate. The initial 51 consecutive benign and malignant cases of the participating units were retrospectively reviewed, but only 366 cancer cases were included in the analysis. Procedures were divided into implementation (ie, the first 10 cases) and postimplementation (ie, case 11 on onwards) groups, and the main outcome was the incidence of local recurrence.

Results: The overall prevalence of local recurrence was 4.1% at a median follow-up of 35 months (interquartile range 20.3-44.2); among implementation and postimplementation groups local recurrence was 7.5% and 3.1%, respectively, and the rate of local recurrence was observed to be nearly 60% lower in the postimplementation group (hazard ratio [95% confidence interval] = 0.43 [0.26-0.72]) Total mesorectal excision specimens were complete or nearly complete in 87.7% of cases, and the circumferential and distal margins were clear in 93.2% and 92.6%, respectively CONCLUSION: Local recurrence rate was low during the learning phase of the transanal total mesorectal excision in a sample of rectal cancer surgeons with acceptable surgical and oncologic outcomes. Both the prevalence and rate of local recurrence were markedly lower in the postimplementation phase, indicating improvement as experience accumulated.
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http://dx.doi.org/10.1016/j.surg.2020.10.018DOI Listing
April 2021

High failure rates following ligation of the intersphincteric fistula tract for transsphincteric anal fistulas: are preoperative MRI measurements of the fistula tract predictive of outcome?

Colorectal Dis 2021 Apr 4;23(4):932-936. Epub 2020 Dec 4.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA.

Aim: Treatment of transsphincteric fistulas (TSFs) with fistulotomy after an indwelling seton is tempered by risks of incontinence and litigation. Thus, ligation of the TSF tract has been popularized as an alternative option. We previously reported on 107 patients who underwent ligation of the intersphincteric fistula tract (LIFT), with a 46% failure rate. Posterior fistula was the only predictor of recurrence. The aim of the present work was to investigate whether the length, width or depth of the fistula measured on preoperative MRI was correlated with recurrence.

Method: Following institutional review board approval, a retrospective analysis of our prospective Complex Anal Fistula Database from 1 January 2011 to 31 August 2019 was performed. Patients with TSF who underwent preoperative MRI and LIFT were included. Fistula location was classified as anterior, posterior or lateral. MRI measurements of fistula length, width and depth (in the intersphincteric groove) were performed. The type and rate of postoperative recurrence were analysed.

Results: 173 patients underwent MRI for an anal fistula; of these 40 underwent LIFT and 22/40 (55%) had preoperative MRI. There was no difference in the length, width or depth of anterior (n = 9), posterior (n = 7) or lateral (n = 6) fistula tracts. The overall recurrence rate was 9/22 (41%). Posterior TSFs had the highest recurrence rate (5/7, 71%).

Conclusion: The mean length, width, and depth of the fistula tract, measured at the preoperative site of LIFT in the intersphincteric groove, did not correlate with recurrence regardless of fistula location.
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http://dx.doi.org/10.1111/codi.15452DOI Listing
April 2021

Indications for, and outcomes of, end ileostomy revision procedures.

Colorectal Dis 2020 Nov 17. Epub 2020 Nov 17.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA.

Aim: Ileostomy complications have been reported in >70% of cases. Older studies have shown ileostomy revision to be required in 23%-38% of patients over a 5-10 year period. There is a paucity of recent data addressing ileostomy revision surgery. We aimed to review end ileostomy revisions in a tertiary centre and analyse indications, procedures performed, outcomes and risks for such surgery.

Methods: This was a retrospective review in a single institution colorectal referral practice. All patients aged >17 years who underwent a revision of an ileostomy at our institution from 2008 to 2019 were included. Indication for ileostomy revision, operative technique (parastomal vs. intra-abdominal) and outcomes including length of stay, readmission rates, wound complications, medical complications and rate of stoma re-revision were assessed.

Results: Fifty-three patients who underwent 72 end ileostomy revision procedures were included; 20 (27.8%) were re-revision procedures. The majority (76.4%) had their original ileostomy created for inflammatory bowel disease. Indications for ileostomy revision were stoma retraction (36.1%), prolapse (22.2%), stenosis (18.1%) and parastomal hernia (29.2%). Of stoma revisions, 55.6% were performed by a parastomal approach vs. 44.4% by an intra-abdominal approach. Procedures were a combination of laparotomy, laparoscopy or both. The average length of stay was statistically significantly lower in the parastomal approach revision group (2.3 days) compared to the intra-abdominal approach revision group (10.3 days) (P < 0.001). Readmission and wound complication rates were 6.9% and 15.3%, respectively, in the intra-abdominal approach group alone. Medical complication rates were 20.8%.

Conclusions: End ileostomy complications are common and surgical treatment may result in significant morbidity, readmission and reoperation. Patients should be counselled about these possibilities.
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http://dx.doi.org/10.1111/codi.15449DOI Listing
November 2020

Clinical role of fluorescence imaging in colorectal surgery - an updated review.

Expert Rev Med Devices 2020 Dec 30;17(12):1277-1283. Epub 2020 Dec 30.

Department of Colorectal Surgery, Cleveland Clinic Florida , Weston, FL, USA.

Introduction: Colorectal surgery has markedly advanced due to the introduction of laparoscopic and robotic surgery. During the past 20 years, these two modalities have been further enhanced by fluorescence imaging.

Areas Covered: This article will review the common and novel uses for fluorophores in colorectal surgery, including tissue perfusion for anastomotic creation, ureter identification, lymphatic mapping, and tumor localization.

Expert Opinion: The versatility of this technology permeates through many aspects of colorectal procedures. The white light spectrum has historically been the only available modality to visualize tissue perfusion, tumor implants, and structures including the ureters and lymph nodes. The ability of the near-infrared spectrum to penetrate biologic tissues allows the identification of these structures with injection of fluorophores. The two most common intravenously utilized fluorophores are methylene blue and indocyanine green. Additionally, novel tumor marker-specific fluorophores are being investigated for purposes of cancer detection.
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http://dx.doi.org/10.1080/17434440.2020.1851191DOI Listing
December 2020
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