Publications by authors named "Vitaliy Poylin"

51 Publications

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection.

Dis Colon Rectum 2021 Mar 22. Epub 2021 Mar 22.

Assistant Professor of Surgery, Northwestern Medicine, Division of Gastrointestinal Surgery, Chicago, IL Assistant Professor of Surgery, Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN. Assistant Professor of Surgery, Rush University Medical Center Department of Surgery, Division of Colon & Rectal Surgery, Chicago, IL. Associate Professor of Surgery, Jewish General Hospital, McGill University, Montreal, Qc Associate Professor, Department of Colorectal Surgery, Digestive Disease Surgery Institute, Cleveland Clinic, Cleveland, OH Associate Professor of Medicine Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN. Associate Professor, Department of Surgery, University of Cincinnati, Cincinnati, OH Professor and Chief, Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ.

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http://dx.doi.org/10.1097/DCR.0000000000002047DOI Listing
March 2021

College of American Pathologists Tumor Regression Grading System for Long-term Outcome in Patients with Locally Advanced Rectal Cancer.

Oncologist 2021 Feb 4. Epub 2021 Feb 4.

Department of Radiation Oncology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.

Background: The National Comprehensive Cancer Network's Rectal Cancer Guideline Panel recommends American Joint Committee of Cancer and College of American Pathologists (AJCC/CAP) tumor regression grading (TRG) system to evaluate pathologic response to neoadjuvant chemoradiotherapy for locally advanced rectal cancer (LARC). Yet, the clinical significance of the AJCC/CAP TRG system has not been fully defined.

Materials And Methods: This was a multicenter, retrospectively recruited, and prospectively maintained cohort study. Patients with LARC from one institution formed the discovery set, and cases from external independent institutions formed a validation set to verify the findings from discovery set. Overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were assessed by Kaplan-Meier analysis, log-rank test, and Cox regression model.

Results: The discovery set (940 cases) found, and the validation set (2,156 cases) further confirmed, that inferior AJCC/CAP TRG categories were closely /ccorrelated with unfavorable survival (OS, DFS, LRFS, and DMFS) and higher risk of disease progression (death, accumulative relapse, local recurrence, and distant metastasis) (all p < .05). Significantly, pairwise comparison revealed that any two of four TRG categories had the distinguished survival and risk of disease progression. After propensity score matching, AJCC/CAP TRG0 category (pathological complete response) patients treated with or without adjuvant chemotherapy displayed similar survival of OS, DFS, LRFS, and DMFS (all p > .05). For AJCC/CAP TRG1-3 cases, adjuvant chemotherapy treatment significantly improved 3-year OS (90.2% vs. 84.6%, p < .001). Multivariate analysis demonstrated the AJCC/CAP TRG system was an independent prognostic surrogate.

Conclusion: AJCC/CAP TRG system, an accurate prognostic surrogate, appears ideal for further strategizing adjuvant chemotherapy for LARC.

Implications For Practice: The National Comprehensive Cancer Network recommends the American Joint Committee of Cancer and College of American Pathologists (AJCC/CAP) tumor regression grading (TRG) four-category system to evaluate the pathologic response to neoadjuvant treatment for patients with locally advanced rectal cancer; however, the clinical significance of the AJCC/CAP TRG system has not yet been clearly addressed. This study found, for the first time, that any two of four AJCC/CAP TRG categories had the distinguished long-term survival outcome. Importantly, adjuvant chemotherapy may improve the 3-year overall survival for AJCC/CAP TRG1-3 category patients but not for AJCC/CAP TRG0 category patients. Thus, AJCC/CAP TRG system, an accurate surrogate of long-term survival outcome, is useful in guiding adjuvant chemotherapy management for rectal cancer.
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http://dx.doi.org/10.1002/onco.13707DOI Listing
February 2021

Vedolizumab does not increase perioperative surgical complications in patients with inflammatory bowel disease, cohort study.

Intest Res 2021 Feb 3. Epub 2021 Feb 3.

Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Background/aims: Biologics are increasingly used to manage ulcerative colitis (UC) and Crohn's disease (CD). However, even with earlier usage of biologic therapy, a significant proportion of patients will require surgery. Vedolizumab is an anti-integrin antibody that is increasingly used given that it is more gut selective and associated with fewer side effects. The aim of this study is to assess the effect of vedolizumab compared to anti-tumor necrosis factor (anti-TNF) therapy on the perioperative complications in patients undergoing surgery for inflammatory bowel disease (IBD).

Methods: Retrospective review of patients treated for IBD at a tertiary care center between 2013 and 2017. Rates of 30- and 90-day complications for patients on vedolizumab were compared to patients on anti-TNF regimens.

Results: One hundred and ninety-nine patients met inclusion criteria with 87 (43%) patients undergoing surgery for CD, 111 (55.8%) for UC and 1 (0.5%) for indeterminate colitis. Thirty-eight patients received preoperative vedolizumab and 94 received anti-TNF. There were more males and lower body mass index in the anti-TNF group. There was no significant difference in overall rate of complications at 30 or 90 days. There was a trend for lower leak rate vedolizumab group (0% for vedolizumab vs. 2.1% for anti-TNF at 30 days, P= 1.00; 0% for vedolizumab vs. 1.1% for anti-TNF at 90 days, P= 1.00). Multivariate analysis showed low albumin ( < 3.6 g/dL) at the time of surgery to be a significant risk factor for overall and infectious complications at 90 days (odds ratio, 3.24; 95% confidence interval, 1.12-8.79; P= 0.021).

Conclusions: Perioperative vedolizumab does not increase rates of perioperative complications in IBD surgery when compared to anti-TNF medications.
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http://dx.doi.org/10.5217/ir.2020.00117DOI Listing
February 2021

Patient's compliance is a contributor to failure of extended antithrombotic prophylaxis in colorectal surgery: prospective cohort study.

Surg Endosc 2021 Jan 25. Epub 2021 Jan 25.

Gastrointestinal and Oncologic Surgery, Feinberg School of Medicine, Northwestern Medical Group, Arkes Family Pavilion, 676 North St Clair Street, Suite 650, Chicago, IL, 60611, USA.

Background: Venous thromboembolic events (VTE) continue to be a major source of morbidity following colorectal surgery. Selective extended VTE prophylaxis for high-risk patients is recommended; however, provider compliance is low. The purpose of this study is to evaluate whether the "global" extended use of enoxaparin in all colorectal patients is feasible and safe.

Methods: This is a prospective study conducted at a tertiary care center. All Patients undergoing elective colorectal procedures from November 1, 2017 to October 31, 2018 were discharged on 30 days of enoxaparin. Safety of use and patient compliance were examined.

Results: Total of 270 patients received extended prophylaxis during the study period (100% of intended patients) with five VTE recorded (1.85%). There was no significant difference in rates of VTE or complications when compared to years of selective prophylaxis (1.26% for 2016, 2.32% for 2017). Only 64% of patients reported full compliance.

Conclusion: Global use of extended enoxaparin prophylaxis is safe, but does not decrease rates of VTE when compared to selective use. Patient's non-adherence is likely a significant contributing factor.
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http://dx.doi.org/10.1007/s00464-020-08271-3DOI Listing
January 2021

Recurrence of Clostridium Difficile and Cytomegalovirus Infections in Patients with Ulcerative Colitis Who Undergo Ileal Pouch-Anal Anastomosis.

Dig Dis Sci 2021 Jan 12. Epub 2021 Jan 12.

Division of Gastrointestinal and Oncologic Surgery, Northwestern Medicine, Arkes Family Pavilion, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA.

Background: Patients with ulcerative colitis (UC) are at increased risk for infections such as Clostridium difficile and cytomegalovirus (CMV) colitis due to chronic immunosuppression. These patients often undergo multiple surgeries putting them at risk for recurrence of the infection. However, rates of recurrence in this setting and outcomes are not well understood.

Aim: The aim of this study is to determine rates of recurrence of C difficile and CMV infection in patients undergoing multistage UC surgeries and effects of antibiotic prophylaxis on outcomes.

Methods: All patients with UC who underwent IPAA between 2001 and 2017 (at two tertiary referral centers were identified. History of C. difficile or CMV colitis prior to any surgery and recurrence after IPAA was noted RESULTS: A total of 633 patients with UC who underwent IPAA were identified, of whom 8.1% patients had C. difficile and 2.7% had CMV infections. 9.8% of C. difficile and 5.9% of CMV patients recurred after IPAA. Rates of abdominal sepsis (14.7% vs. 12.7%), 90-day mortality (0% vs. 0.4%), pouchitis (36.8% vs. 45.0%), or return to stoma (7.4% vs. 5.4%) were similar between patients who did or did not have infections. In patients with C. difficile infection prior to first surgery, none of the patients who received prophylaxis had recurrent infection.

Conclusions: Rates of C. difficile and CMV infections remain high in patients undergoing surgery for UC, with substantial minority developing recurrent infection during subsequent surgical procedures. Antibiotic prophylaxis in patients with a history of C difficile may reduce the rate of recurrent infection.
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http://dx.doi.org/10.1007/s10620-020-06772-8DOI Listing
January 2021

Implementation of extended prolonged venous thromboembolism prophylaxis with rivaroxaban after major abdominal and pelvic surgery - overview of safety and early outcomes.

Pol Przegl Chir 2020 Sep;92(6):22-27

Department of Surgery and Proctology and Gastrointestinal Surgery, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine.

<b>Purpose: </b>Venous thromboembolism (VTE) after colorectal surgery is a well-documented complication, resulting in a general recommendation of extended post-discharge prophylaxis. Rivaroxaban, a factor Xa inhibitor, is a daily tablet approved for treatment of VTE and prophylaxis after orthopedic surgery. <br><b>Aim: </b>The purpose of this study is to evaluate the safety of rivaroxaban for extended prophylaxis after major abdominal and pelvic surgery. <br><b>Methods: </b>This is a retrospective review of patients undergoing major colorectal surgery at a regional hospital in Kiev, Ukraine. Patients received peri-operative VTE prophylaxis with subcutaneous heparin and then transitioned to rivaroxaban for a total of 30 days. Occurrences of major or minor bleeding, blood transfusion, and a need for re-intervention were noted. Phone surveys were administered on post-operative day 30 to assess compliance and satisfaction with the regimen. <br><b>Results: </b>A total of 51 patients were included in the study with an average age of 62.4 years. Seventy-one percent of the cases were abdominal, 29% were pelvic cases and 59% were done laparoscopically. There was one episode of major intra-abdominal bleeding requiring return to the operating room. There were 2 minor bleeding episodes which did not require intervention. There were no VTE events in the group. The phone survey response rate was 100%. All but one patient reported having completed the full course of rivaroxaban. Patients reported that oral prophylaxis was easy to adhere to and preferable compared to injections. <br><b>Conclusion: </b>Implementation of extended prophylaxis with rivaroxaban is easy, safe and does not increase rates of postoperative bleeding.
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http://dx.doi.org/10.5604/01.3001.0014.4208DOI Listing
September 2020

Biological welding - novel technique in the treatment of esophageal metaplasia.

Pol Przegl Chir 2020 Apr;92(5):1-5

Department of Surgery and Proctology, Gastrointestinal Surgery, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine.

<b>Introduction:</b> Biological welding - controlled action of high frequency current on living tissues, which leads to their structural changes and weld formation - connection with unique biological properties (strength, high elasticity, insensitivity to microbial infection, stimulating effect on the regeneration process, speed and quality which surpasses the normal uncomplicated healing) [22]. This method is used in various fields of surgery, but at the moment there is no data on its use in case of esophageal cylindrocellular (intestinal) metaplasia (further esophageal metaplasia or Barrett's esophagus). <br><b>Objective:</b> The goal of this study is to evaluate biologic welding as a treatment option for patients with Barrett's esophagus. <br><b>Materials and methods:</b> Single-center retrospective review of patients with short-segment Barrett's esophagus and metaplasia were treated by argon plasma coagulation (APC) or Paton's welding. This was followed by Nissen fundoplication. Primary outcome of this study was mucosal healing with morphological confirmation of the absence of metaplasia. The groups included patients with a short segment of the esophagus Barrett's C2-3M3-4 (Prague Classification 2004) and high dysplasia without nodule formation in combination with hiatal hernia (VI World Congress of the International Society for Esophageal Diseases; ISED) [23-25]). <br><b>Results:</b> A total of 49 patients were included in the study with 25 patients treated by APC laser and 24 by biowelding. Four patients (16.0%) in the APC group developed stenosis and 5 patients (20.0%) developed recurrence compared to none in the biowelding group. Patients in the biowelding group had a significantly faster rate of mucosal healing leading to faster progression to Nissen fundoplication (at average 53 days) compared to APC laser group (surgery at 115 days). <br><b>Conclusions:</b> Biological welding of Paton's is a safe and effective treatment option for patients with esophageal metaplasia.
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http://dx.doi.org/10.5604/01.3001.0014.1176DOI Listing
April 2020

An Invited Commentary on original article title "Survival outcome of palliative primary tumor resection for colorectal cancer patients with synchronous liver and/or lung metastases".

Authors:
Vitaliy Y Poylin

Int J Surg 2020 09 12;81:147-148. Epub 2020 Aug 12.

Gastrointestinal Surgery, Northwestern Medical Group, Feinberg School of Medicine, Arkes Family Pavilion, 676 North St Clair Street, Suite 650, Chicago, IL, 60611, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ijsu.2020.08.007DOI Listing
September 2020

Effectiveness of the Ileostomy Pathway in Reducing Readmissions for Dehydration: Does It Stand the Test of Time?

Dis Colon Rectum 2020 08;63(8):1151-1155

Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.

Background: The ileostomy pathway, introduced in 2011, has proved to be successful in eliminating hospital readmissions for high-output ileostomy or dehydration in the following period of 7 months in a single institution. However, it is unclear whether this short-term success, immediately after the initiation of the program, can be sustainable in the long term.

Objective: The aim of this study was to assess the efficacy and the durability of the ileostomy pathway in reducing readmissions for dehydration over a longer period of time.

Design: This was a retrospective review of the patients who entered into the ileostomy pathway, since its introduction on March 1, 2011, until January 31, 2015.

Settings: This study was conducted at a tertiary academic center.

Patients: Patients undergoing colorectal surgery with the creation of a new end or loop ileostomy were included.

Intervention: The long-term sustainability of the ileostomy pathway was assessed.

Main Outcome Measures: The primary end point was readmission within 30 days after discharge for a high-output ileostomy or dehydration.

Results: A total of 393 patients (male n = 195, female n = 198, median age 52 (18-87) years) were included: 161 prepathway and 232 on-pathway. Overall 30-day postdischarge readmission rates decreased from 35.4% to 25.9% (p = 0.04). Readmissions due to high output and/or dehydration dropped from 15.5% to 3.9% (p < 0.001). Readmissions due to small-bowel obstructions dropped from 9.9% to 4.3%, (p = 0.03).

Limitations: The possible limitations of the study included a nonrandomized comparison of the patient groups and those patients who were possibly admitted to different institutions.

Conclusions: The present ileostomy pathway decreases readmissions for high-output ileostomy and dehydration in patients with new ileostomies and is durable in the long term. See Video Abstract at http://links.lww.com/DCR/B233. EFICACIA DE VÍA DE ILEOSTOMÍA PARA REDUCIR LOS REINGRESOS POR DESHIDRATACIÓN: ¿RESISTE LA PRUEBA DEL TIEMPO?: La vía de ileostomía, introducida en 2011, ha demostrado ser exitosa en la eliminación de reingresos hospitalarios por ileostomía de alto rendimiento o deshidratación, por un período de 7 meses, en una sola institución. Sin embargo, no se ha aclarado si el éxito es a corto plazo, inmediatamente después del inicio del programa, y de que pueda ser sostenible a largo plazo.El objetivo de este estudio fue evaluar la eficacia y la durabilidad de la vía de ileostomía, para disminuir los reingresos por deshidratación, durante un período de tiempo más largo.Esta fue una revisión retrospectiva de pacientes que ingresaron a la vía de ileostomía, desde su introducción el 1 de marzo de 2011 hasta el 31 de enero de 2015.Este estudio se realizó en un centro académico terciario.Se incluyeron pacientes sometidos a cirugía colorrectal con la creación de una nueva ileostomía de extremo o asa.Evaluar la sostenibilidad de la vía de ileostomía a largo plazo.El punto final primario fue el reingreso dentro de los 30 días posteriores al alta, por una ileostomía de alto gasto o deshidratación.Se incluyeron un total de 393 pacientes (hombres n = 195, mujeres n = 198, edad media 52 [18-87] años), 161 antes de la vía y 232 en la vía. En general, las tasas de reingreso después del alta a 30 días, disminuyeron de 35.4% a 25.9% (p = 0.04). Los reingresos por alto rendimiento y / o deshidratación, disminuyeron del 15.5% al 3.9% (p < 0.001). Los reingresos debidos a obstrucciones del intestino delgado, disminuyeron del 9.9% al 4.3% (p = 0.03).Las posibles limitaciones del estudio incluyeron una comparación no aleatoria de los grupos de pacientes, y de aquellos pacientes que posiblemente fueron admitidos en diferentes instituciones.La vía de ileostomía disminuye los reingresos por ileostomía de alto gasto y deshidratación, en nuevos pacientes con ileostomía, y es duradera a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B233.
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http://dx.doi.org/10.1097/DCR.0000000000001627DOI Listing
August 2020

Rate of urinary retention after ileostomy takedown in men and role of routine placement of urinary catheter.

Updates Surg 2020 Dec 27;72(4):1181-1185. Epub 2020 Apr 27.

Gastrointestinal Surgery Northwestern Medicine, Feinberg School of Medicine, 676 North St Clair Street, Suite 650, Chicago, IL, 60611, USA.

Ileostomy takedown has been proposed as one of the procedures where the placement of the catheters can be avoided, however, the rate of UR after ileostomy takedown is unknown. The aim of this study is to investigate the rate of UR after ileostomy takedown and the potential benefit of perioperative Tamsulosin. Retrospective cohort study of men undergoing ileostomy takedown after pelvic colorectal surgery between January 2009 and December 2016. A total of 100 patients were identified. The rate of UR after ileostomy takedown was high at 26%. There were no instances of urinary tract infection, however, most instances of UR were in patients who did not have catheter in surgery (96% vs. 4%, p = 0.044). Perioperative use of tamsulosin did not result in significant decrease in urinary retention. Rates of urinary retention after ileostomy takedown are high. Although not placing the catheter may be protective against urinary tract infections, patients should be counseled about the possibility of UR after ileostomy takedown.
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http://dx.doi.org/10.1007/s13304-020-00763-0DOI Listing
December 2020

Correction to: Surgeon-delivered laparoscopic transversus abdominis plane blocks are non-inferior to anesthesia-delivered ultrasound-guided transversus abdominis plane blocks: a blinded, randomized non-inferiority trial.

Surg Endosc 2020 Jul;34(7):3020

Division of Colon & Rectum Surgery, Beth Israel Lahey Health Medical Center, Harvard Medical School, Boston, MA, 02215, USA.

The following text should have been included in the Acknowledgments.
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http://dx.doi.org/10.1007/s00464-020-07505-8DOI Listing
July 2020

Surgery for ulcerative colitis in geriatric patients is safe with similar risk to younger patients.

Eur J Gastroenterol Hepatol 2019 Nov;31(11):1356-1360

Surgery and Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Objective: A prior study indicated that postoperative mortality and complications were higher in geriatrics with inflammatory bowel disease (IBD). We sought to assess the rates of surgical complications and mortality in patients aged ≥65 years after colectomy for ulcerative colitis (UC).

Methods: This is a single center retrospective study at a tertiary care center. We reviewed all hospital discharges with ICD-9 code 556.X between January 2002 and January 2014. Patients were included if they underwent a colectomy for UC. All records were manually reviewed for demographics, complications and mortality within 90 days postoperatively.

Results: A total of 259 patients underwent surgery for UC during the study period and 34 patients were ≥65 years old (range 65-82) at the time of their surgery. There was no difference in overall length of stay (10.5 days vs. 9.6 days; P = 0.645) or complication rates (44% vs. 47%; P = 0.854) in the ≥65 cohort compared with the under 65 cohort. Mortality was higher in the geriatric cohort but this included only two deaths within 90 days, one of which was unrelated to the surgery, compared with one death related to surgery within 90 days in the younger cohort. Readmissions occurred in 24% of both cohorts within 90 days.

Conclusion: Geriatric patients undergoing surgery for UC are not at increased risk of surgery-related morbidity or mortality compared with a younger cohort.
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http://dx.doi.org/10.1097/MEG.0000000000001529DOI Listing
November 2019

Surgeon-delivered laparoscopic transversus abdominis plane blocks are non-inferior to anesthesia-delivered ultrasound-guided transversus abdominis plane blocks: a blinded, randomized non-inferiority trial.

Surg Endosc 2020 07 4;34(7):3011-3019. Epub 2019 Sep 4.

Division of Colon & Rectum Surgery, Beth Israel Lahey Health Medical Center, Harvard Medical School, Boston, MA, 02215, USA.

Background: The transversus abdominis plane (TAP) block is an important non-narcotic adjunct for post-operative pain control in abdominal surgery. Surgeons can use laparoscopic guidance for TAP block placement (LTAP), however, direct comparisons to conventional ultrasound-guided TAP (UTAPs) have been lacking. The aim of this study is to determine if surgeon placed LTAPs were non-inferior to anesthesia placed UTAPs for post-operative pain control in laparoscopic colorectal surgery.

Methods: This was a prospective, randomized, patient and observer blinded parallel-arm non-inferiority trial conducted at a single tertiary academic center between 2016 and 2018 on adult patients undergoing laparoscopic colorectal surgery. Narcotic consumption and pain scores were compared for LTAP vs. UTAP for 48 h post-operatively.

Results: 60 patients completed the trial (31 UTAP, 29 LTAP) of which 25 patients were female (15 UTAP, 10 LTAP) and the mean ages (SD) were 60.0 (13.6) and 61.5 (14.3) in the UTAP and LTAP groups, respectively. There was no significant difference in post-operative narcotic consumption between UTAP and LTAP at the time of PACU discharge (median [IQR] milligrams of morphine, 1.8 [0-4.5] UTAP vs. 0 [0-8.7] LTAP P = .32), 6 h post-operatively (5.4 [1.8-17.1] UTAP vs. 3.6 [0-12.6] LTAP P = .28), at 12 h post-operatively (9.0 [3.6-29.4] UTAP vs. 7.2 [0.9-22.5] LTAP P = .51), at 24 h post-operatively (9.0 [3.6-29.4] UTAP vs. 7.2 [0.9-22.5] LTAP P = .63), and 48 h post-operatively (39.9 [7.5-70.2] UTAP vs. 22.2 [7.5-63.8] LTAP P = .41). Patient-reported pain scores as well as pre-, intra-, and post-operative course were similar between groups. Non-inferiority criteria were met at all post-op time points up to and including 24 h but not at 48 h.

Conclusions: Surgeon-delivered LTAPs are safe, effective, and non-inferior to anesthesia-administered UTAPs in the immediate post-operative period.

Trial Registry: The trial was registered at clinicaltrials.gov Identifier NCT03577912.
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http://dx.doi.org/10.1007/s00464-019-07097-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7103091PMC
July 2020

Rectal-prolapse repair in men is safe, but outcomes are not well understood.

Gastroenterol Rep (Oxf) 2019 Aug 9;7(4):279-282. Epub 2019 May 9.

University of Iowa, Iowa City, IA, USA.

Introduction: Rectal prolapse is a condition that occurs infrequently in men and there is little literature guiding treatment in this population. The purpose of this study was to evaluate the surgical approach and outcomes of rectal-prolapse repair in men.

Methods: A retrospective multicenter review was conducted of consecutive men who underwent rectal-prolapse repair between 2004 and 2014. Surgical approaches and outcomes, including erectile function and fecal continence, were evaluated.

Results: During the study period, 58 men underwent rectal-prolapse repair and the mean age of repair was 52.7 ± 24.1 years. The mean follow-up was 13.2 months (range, 0.5-117 months). The majority of patients underwent endoscopic evaluation (78%), but few patients underwent anal manometry (16%), defecography (9%) or ultrasound (3%). Ten patients (17%) underwent biofeedback/pelvic-floor physical therapy prior to repair. Nineteen patients (33%) underwent a perineal approach (most were perineal proctosigmoidectomy). Thirty-nine patients (67%) underwent repair using an abdominal approach (all were suture rectopexy) and, of these, 77% were completed using a minimally invasive technique. The overall complication rate was 26% including urinary retention (16%), which was more common in patients undergoing the perineal approach (32% vs. 8%,  = 0.028), urinary-tract infection (7%) and wound infection (3%). The overall recurrence rate was 9%, with no difference between abdominal and perineal approaches. Information on sexual function was missing in the majority of patients  both before and after surgery (76% and 78%, respectively).

Conclusion:  Rectal-prolapse repair in men is safe and has a low recurrence rate; however, sexual function was poorly recorded across all institutions. Further studies are needed to evaluate to best approach to and functional outcomes of rectal-prolapse repair in men.
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http://dx.doi.org/10.1093/gastro/goz016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688730PMC
August 2019

Rectal eversion: safe and effective way to achieve low transaction in minimally invasive Ileal pouch-anal anastomosis surgery, short- and long-term outcomes.

Surg Endosc 2020 03 10;34(3):1290-1293. Epub 2019 Jun 10.

Northwestern Medicine Digestive Health Center Arkes Pavilion, 676 N. St. Clair St., Suite 650, Chicago, IL, 60611, USA.

Background: Ileal pouch-anal anastomosis remains a gold standard in restoring continence in patient with ulcerative colitis. Achieving low transection can be challenging and may require mucosectomy with a hand-sewn anastomosis. Rectal eversion (RE) technique provides a safe and effective alternative for both open and minimally invasive approaches. The purpose of this study is to evaluate short- and long-term outcomes of patients who underwent RE when compared to those who underwent conventional trans-abdominal transection.

Materials And Methods: This is a retrospective review performed at tertiary care center. Patients undergoing proctectomy and pouch surgery by either standard approach or with RE from November 2004 to January 2017 were evaluated. Demographics, post-operative complications, as well as 1- and 3-year functional outcomes were analyzed.

Results: Total of 176 underwent proctocolectomy with creation of a J pouch and 88 (50%) had the RE technique utilized. The RE group had a higher rate of corticosteroid use at the time of surgery 59.1 versus 39.8% (p = 0.0156), but otherwise groups were statistically similar. 20 cases (26.1%) of RE group and 54 (61%) of conventional group cases were accomplished in minimally invasive fashion. There was no difference in the rates of 30- and 90-day complications. Functional outcomes data were available for up to 78.4% of patient with trans-abdominal approach and 64.7% in RE group. At 1 and 3 years after surgery, there was no difference in the number of bowel movements, fecal incontinence, or nocturnal bowel movements. The rates of returning to ileostomy or pouch revision were the same.

Conclusion: RE technique is safe and effective way to achieve a low transaction in J pouch surgery. The technique provides similar functional outcomes at 1 and 3 years after surgery and can be particularly useful in minimally invasive approaches.
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http://dx.doi.org/10.1007/s00464-019-06896-7DOI Listing
March 2020

Surgery in the age of biologics.

Gastroenterol Rep (Oxf) 2019 Apr 11;7(2):77-90. Epub 2019 Mar 11.

Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.
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http://dx.doi.org/10.1093/gastro/goz004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454839PMC
April 2019

Calcium Intake and Survival after Colorectal Cancer Diagnosis.

Clin Cancer Res 2019 03 13;25(6):1980-1988. Epub 2018 Dec 13.

Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

Purpose: Although evidence suggests an inverse association between calcium intake and colorectal cancer incidence, the influence of calcium on survival after colorectal cancer diagnosis remains unclear. We prospectively assessed the association of postdiagnostic calcium intake with colorectal cancer-specific and overall mortality among 1,660 nonmetastatic colorectal cancer patients within the Nurses' Health Study and the Health Professionals Follow-up Study. Patients completed a validated food frequency questionnaire between 6 months and 4 years after diagnosis and were followed up for death. Multivariable hazard ratios (HRs) and 95% confidence intervals (95% CI) were calculated using Cox proportional hazards regression.

Results: Comparing the highest with the lowest quartile intake of postdiagnostic total calcium, the multivariable HRs were 0.56 (95% CI, 0.32-0.96; = 0.04) for colorectal cancer-specific mortality and 0.80 (95% CI, 0.59-1.09; = 0.11) for all-cause mortality. Postdiagnostic supplemental calcium intake was also inversely associated with colorectal cancer-specific mortality (HR, 0.67; 95% CI, 0.42-1.06; = 0.047) and all-cause mortality (HR, 0.71; 95% CI, 0.54-0.94; = 0.008), although these inverse associations were primarily observed in women. In addition, calcium from diet or dairy sources was associated with lower risk in men.

Conclusions: Higher calcium intake after the diagnosis may be associated with a lower risk of death among patients with colorectal cancer. If confirmed, these findings may provide support for the nutritional recommendations of maintaining sufficient calcium intake among colorectal cancer survivors.
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http://dx.doi.org/10.1158/1078-0432.CCR-18-2965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7023298PMC
March 2019

Structured versus narrative reporting of pelvic MRI in perianal fistulizing disease: impact on clarity, completeness, and surgical planning.

Abdom Radiol (NY) 2019 03;44(3):811-820

Division of Abdominal Imaging/Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02115, USA.

Objective: To evaluate clarity, completeness, and impact on surgical planning of MRI reporting of perianal fistulizing disease using a structured disease-specific template versus narrative reporting for planning of disease treatment by colorectal surgeons.

Materials And Methods: In this HIPAA-compliant, IRB-approved study with waiver of informed consent, a structured reporting template for perianal fistulizing disease MRIs was developed based on collaboration between colorectal surgeons and abdominal radiologists. The study population included 45 consecutive patients who underwent pelvic MRI for perianal fistulizing disease prior to implementation of structured reporting, and 60 consecutive patients who underwent pelvic MRI for perianal fistulizing disease after implementation of structured reporting. Objective evaluation of the reports for the presence of 12 key features was performed, as also subjective evaluation regarding the clarity and completeness of reports, and impact on surgical planning.

Results: Significantly more key features were absent in narrative reports [mean: 6.3 ± 1.8 (range 3-11)] than in structured reports [mean: 0.3 ± 0.9 (range 1-5)] (p ≤ 0.001). The use of structured reporting also increased the percentage of completeness (72.5-88.3% for surgeon 1, and 61.2-81.3% for surgeon 2; p = 0.05 and 0.03, respectively), helpfulness in surgical planning (7.1 ± 1.5-7.6 ± 1.5 for surgeon 1, and 5.8 ± 1.4-7.1 ± 1.1 for surgeon 2; p = 0.05 and p < 0.001, respectively), and clarity (7.6 ± 1.3-8.3 ± 1.1 for surgeon 1, and 5.2 ± 1.4-7.1 ± 1.3 for surgeon 2; p = 0.006 and p < 0.001, respectively) of the reports.

Conclusion: Structured MRI reports in patients with perianal fistulizing disease miss fewer key features than narrative reports. Moreover, structured reports were described as more complete and clear, and more helpful for treatment planning.
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http://dx.doi.org/10.1007/s00261-018-1858-8DOI Listing
March 2019

Synchronous granular cell tumors of the pancreas and cecum.

Clin Imaging 2018 Nov - Dec;52:95-99. Epub 2018 Jul 20.

Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA. Electronic address:

Granular cell tumors (GCT) are rare and typically benign. Diagnosis is challenging due to nonspecific imaging characteristics and symptomatology. Herein, we report a combination of pancreatic/cecal GCTs in a 43-year-old man. Contrast enhanced MDCT demonstrated a 1.5 cm well-defined homogeneous intraluminal cecal mass and a 1.6 cm slightly hypervascular pancreatic body mass. On MRI, the pancreatic mass showed increased enhancement on post-gadolinium delayed sequences. Diagnosis was confirmed by excisional pathology (S100 and CD68, PAS-D positive). Radiologists, gastroenterologists, and surgeons should ponder the possibility of GCTs in the differential diagnosis of any small, pancreatic or cecal well-defined tumor.
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http://dx.doi.org/10.1016/j.clinimag.2018.07.011DOI Listing
January 2019

Robotic Excision of Retrorectal Mass.

J Gastrointest Surg 2018 10 15;22(10):1811-1813. Epub 2018 Jun 15.

Department of Surgery, Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.

Background: Retrorectal cysts make up a small but challenging group of pelvic masses, especially if they extend high into the pelvis. We present a case of successful robotic removal of a large retrorectal cyst.

Methods: Video presentation of a robotic excision of a retrorectal mass.

Results: We present a case of robotic removal of a large retrorectal mass extending up to the S3 vertebra.

Discussion: Robotic approach is a very useful tool for successful removal of large pelvic masses that cannot be removed by traditional posterior or trans perineal approach.
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http://dx.doi.org/10.1007/s11605-018-3838-2DOI Listing
October 2018

The impact of surgeon choices on costs associated with uncomplicated minimally invasive colectomy: you are not as important as you think.

Gastroenterol Rep (Oxf) 2018 May 27;6(2):108-113. Epub 2017 Sep 27.

Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Background: There is increasing public discussion about the escalating cost of healthcare in America. There are no published data regarding the contribution of individual surgeons' choices on the cost of uncomplicated minimally invasive colectomy.

Methods: A review of a hospital cost-accounting database of the direct costs related to the index operation and post-operative care of all patients who underwent elective minimally invasive segmental colectomy over a 1-year period was performed.

Results: A total of 111 cases were enrolled in this study, 18 of which were performed robotically. The average direct cost after minimally invasive colectomy was $5536. The cost of robotic colectomy was 53% greater than laparoscopic ($7806 vs $5096,  < 0.001). There was no statistically significant difference in overall costs among laparoscopic cases performed by three surgeons ($5099 vs $5108 vs $5055,  = 0.987). Average operating room supply costs among the three surgeons were $1236, $1105 and $1030, respectively ( = 0.067), with a standard deviation of $328 (6.4% of overall cost).

Conclusions: No significant difference in overall costs between surgeons was demonstrated despite varied training, experience levels and operative techniques. Total costs are relatively institutionally fixed and minimally influenced by variations in individual surgeon preferences.
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http://dx.doi.org/10.1093/gastro/gox035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5952919PMC
May 2018

Mortality Is Rare Following Elective and Non-elective Surgery for Ulcerative Colitis, but Mild Postoperative Complications Are Common.

Dig Dis Sci 2018 Mar 20;63(3):713-722. Epub 2018 Jan 20.

Department of Surgery and Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Background Data: Currently, data regarding the rates of morbidity and mortality following non-elective colectomy for ulcerative colitis (UC) are variable. We sought to determine the rates and predictors of 90-day mortality and complications following colectomy for UC.

Methods: Patients undergoing an initial surgery for UC at a tertiary care center between January 2002 and January 2014 were included. Patients were identified using ICD-9 code 556.x. Each record was manually reviewed for demographic information, medical histories, UC history, medications, and data regarding the admission and discharge. Charts were reviewed for mortality and complications within 90 days of surgery. Complications were classified using the Clavien-Dindo classification system. Univariate and multivariate analyses were performed using IBM SPSS Statistics, version 23.0.

Results: Two hundred and fifty-eight patients underwent surgery for UC. 69% were elective, and 31% were urgent/emergent. There were no deaths reported within 30 days of surgery. At 90 days, there were 2 deaths in the elective group and 1 death in the urgent/emergent group. The death in the urgent/emergent group was likely related to the initial surgery, while the elective group death was not directly related to the initial surgery for UC. Complications occurred in 47% of patients. There were no significant differences in rates of complications in either surgical cohort. Majority (62%) of the complications were Clavien-Dindo grade 1 or 2 with no difference in the elective or urgent/emergent group. Unplanned readmissions occurred in 24% of cases.

Conclusion: Surgery for UC is not associated with any mortality at 30 days and very low mortality at 90 days. However, surgery is associated with an increased rate of minor postoperative complications and readmissions.
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http://dx.doi.org/10.1007/s10620-018-4922-xDOI Listing
March 2018

Rectal Eversion Technique: A Method to Achieve Very Low Rectal Transection and Anastomosis With Particular Value in Laparoscopic Cases.

Dis Colon Rectum 2017 Dec;60(12):1329-1331

Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Introduction: Transection of the rectum at the anorectal junction is required for proper resection in ulcerative colitis and restorative proctocolectomy. Achieving stapled transection at the pelvic floor is often challenging, particularly during laparoscopic proctectomy. Transanal mucosectomy and handsewn anastomosis are frequently used to achieve adequate resection. Rectal eversion provides an alternative for low anorectal transection and maintains the ability to perform stapled anastomosis.

Technique: The purpose of this article is to describe a technique for low anorectal transection. The work was conducted at tertiary care center by 2 colon and rectal surgeons on patients undergoing total proctocolectomy with creation of ileal pouch rectal anastomosis for ulcerative colitis. We measured the ability to achieve low stapled anastomosis.

Results: Very low transection was achieved, allowing for creation of IPAA without leaving significant rectal cuff. This study was limited because it is an early experience that was not performed in the setting of a scientific investigation. No sphincter or bowel functional data were obtained or evaluated.

Conclusions: Rectal eversion technique provides an alternative to mucosectomy when low pelvic transection is difficult to achieve. See Video at http://links.lww.com/DCR/A441.
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http://dx.doi.org/10.1097/DCR.0000000000000932DOI Listing
December 2017

Erratum to: Primary vs. delayed perineal proctectomy-there is no free lunch.

Int J Colorectal Dis 2017 08;32(8):1213

Department of Surgery, Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1007/s00384-017-2838-0DOI Listing
August 2017

Primary vs. delayed perineal proctectomy-there is no free lunch.

Int J Colorectal Dis 2017 Aug 6;32(8):1207-1212. Epub 2017 May 6.

Department of Surgery, Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Purpose: Perineal wound complications associated with anorectal excision are associated with prolonged wound healing and readmission. In order to avoid these problems, the surgeon may choose to leave the anorectum in situ. The purpose of this study is to compare complications and outcomes after primary vs. delayed anorectum removal.

Methods: A retrospective review of all patients undergoing proctectomy or proctocolectomy with permanent stoma between 2004 and 2014 in a single tertiary institution was conducted.

Results: During the study period, we identified 117 proctectomy patients; 69 (59%) patients had anorectum removed at index operation and 41% had the anorectum left in place. Patients with retained anorectum developed pelvic abscess significantly more frequently as compared to the other group (23 vs. 4%, p = 0.003). In patients with primary anorectum removal, 22 (32%) had perineal complications and 10 (15%) required reoperations. In patients with retained anorectum, 12 patients (25%) came back for delayed perineal proctectomy at a mean time of 277 days after the index operation; 7 of those (58%) developed postoperative wound complications. There was no difference in time to perineal wound healing between primary and delayed perineal proctectomy group (154 vs. 211 days, p = 0.319).

Conclusion: Surgery involving the distal rectum is associated with a significant number of infectious perineal complications. Although leaving the anorectum in place avoids a primary perineal wound, both approaches are associated with a significant number of complications including reoperation.
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http://dx.doi.org/10.1007/s00384-017-2790-zDOI Listing
August 2017

Functional Disorders: Slow-Transit Constipation.

Clin Colon Rectal Surg 2017 Feb;30(1):76-86

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Constipation is a very common complaint, with slow-transit constipation (STC) accounting for a significant proportion of cases. Old age, female gender, psychiatric illness, and history of sexual abuse are all associated with STC. The exact cause of STC remains elusive; however, multiple immune and cellular changes have been demonstrated. Diagnosis requires evidence of slowed colonic transit which may be achieved via numerous modalities. While a variety of medical therapies exist, these are often met with limited success and a minority of patients ultimately require operative intervention. When evaluating a patient with STC, it is important to determine the presence of concomitant obstructed defecation or other forms of enteric dysmotility, as this may affect treatment decisions. Although a variety of surgical procedures have been reported, subtotal colectomy with ileorectal anastomosis is the most commonly performed and well-studied procedure, with the best track record of success.
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http://dx.doi.org/10.1055/s-0036-1593436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5179270PMC
February 2017

Post operative stereotactic radiosurgery for positive or close margins after preoperative chemoradiation and surgery for rectal cancer.

J Gastrointest Oncol 2016 Jun;7(3):315-20

1 Department of Radiation Oncology, Istanbul University, Istanbul, Turkey ; 2 Radiation Oncology, 3 Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.

Background: The incidence of positive margins after neoadjuvant chemoradiation and adequate surgery is very low. However, when patients do present with positive or close margins, they are at a risk of local failure and local therapy options are limited. We evaluated the role of stereotactic body radiotherapy (SBRT) in patients with positive or close margins after induction chemoradiation and total mesorectal excision.

Methods: This is a retrospective evaluation of patients treated with SBRT after induction chemoradiation and surgery for positive or close margins. Seven evaluable patients were included. Fiducial seeds were place at surgery. The Cyberknife(TM) system was used for planning and treatment. Patients were followed 1 month after treatment and 3-6 months thereafter. Descriptive statistics and Kaplan-Meir method was used to repot the findings.

Results: Seven patients (3 men and 4 women) were included in the study with a median follow-up of 23.5 months. The median initial radiation dose was 5,040 cGy (in 28 fractions) and the median SBRT dose was 2,500 cGy (in 5 fractions). The local control at 2 years was 100%. The overall survival at 1 and 2 years was 100% and 71% respectively. There was no Grade III or IV toxicity.

Conclusions: SBRT reirradiation is an effective and safe method to address positive or close margins after neoadjuvant chemoradiation and surgery for rectal cancer.
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http://dx.doi.org/10.21037/jgo.2015.11.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880783PMC
June 2016

Complications Following Anorectal Surgery.

Clin Colon Rectal Surg 2016 Mar;29(1):14-21

Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Anorectal surgery is well tolerated. Rates of minor complications are relatively high, but major postoperative complications are uncommon. Prompt identification of postoperative complications is necessary to avoid significant patient morbidity. The most common acute complications include bleeding, infection, and urinary retention. Pelvic sepsis, while may result in dramatic morbidity and even mortality, is relatively rare. The most feared long-term complications include fecal incontinence, anal stenosis, and chronic pelvic pain.
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http://dx.doi.org/10.1055/s-0035-1568145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755765PMC
March 2016