User login
Consider intraperitoneal ropivacaine for colectomy ERAS
SEATTLE – Intraperitoneal ropivacaine decreases postoperative pain and improves functional recovery after laparoscopic colectomy, according to randomized, blinded trial from the Royal Adelaide (Australia) Hospital.
“We recommend routine inclusion of IPLA [intraperitoneal local anesthetic] in the multimodal analgesia component of ERAS [enhanced-recovery-after-surgery] programs for laparoscopic colectomy,” the investigators concluded.
Recovery was smoother in the ropivacaine group. On a 90-point surgical recovery scale assessing fatigue, mental function, and the ability to do normal daily activities, ropivacaine patients were a few points ahead on days 1 and 3; the gap widened to about 10 points on days 7, 30, and 45. Ropivacaine might have helped reduced inflammation, accounting for the extended benefit, Dr. Lewis said.
Pain control was better with ropivacaine, as well. Ropivacaine patients were about 15-20 points lower on 50-point scales assessing both visceral and abdominal pain at postop hours 3 and 24, and day 7. The findings were statistically significant.
Several trends also favored ropivacaine. Ropivacaine patients had their first bowel movement at around 70 hours postop, versus about 82 hours in the control group. They were also discharged almost a day sooner, and had less postop vomiting. Just one patient in the ropivacaine group was diagnosed with ileus, versus four in the control arm.
There was also a trend for less opioid use in the ropivacaine group, which Dr. Lewis suspected would have been statistically significant if the trial had more patients.
Ropivacaine patients were a mean of 67 years old, versus 62 years old in the control group. There were slightly more men than women in each arm. The mean body mass index in the ropivacaine group was 28.5 kg/m2, and in the control group 26.4 kg/m2. Ropivacaine was discontinued in two patients due to possible toxicity.
An audience member noted that intravenous lidocaine has shown similar benefits in abdominal surgery.
The investigators had no disclosures.
SEATTLE – Intraperitoneal ropivacaine decreases postoperative pain and improves functional recovery after laparoscopic colectomy, according to randomized, blinded trial from the Royal Adelaide (Australia) Hospital.
“We recommend routine inclusion of IPLA [intraperitoneal local anesthetic] in the multimodal analgesia component of ERAS [enhanced-recovery-after-surgery] programs for laparoscopic colectomy,” the investigators concluded.
Recovery was smoother in the ropivacaine group. On a 90-point surgical recovery scale assessing fatigue, mental function, and the ability to do normal daily activities, ropivacaine patients were a few points ahead on days 1 and 3; the gap widened to about 10 points on days 7, 30, and 45. Ropivacaine might have helped reduced inflammation, accounting for the extended benefit, Dr. Lewis said.
Pain control was better with ropivacaine, as well. Ropivacaine patients were about 15-20 points lower on 50-point scales assessing both visceral and abdominal pain at postop hours 3 and 24, and day 7. The findings were statistically significant.
Several trends also favored ropivacaine. Ropivacaine patients had their first bowel movement at around 70 hours postop, versus about 82 hours in the control group. They were also discharged almost a day sooner, and had less postop vomiting. Just one patient in the ropivacaine group was diagnosed with ileus, versus four in the control arm.
There was also a trend for less opioid use in the ropivacaine group, which Dr. Lewis suspected would have been statistically significant if the trial had more patients.
Ropivacaine patients were a mean of 67 years old, versus 62 years old in the control group. There were slightly more men than women in each arm. The mean body mass index in the ropivacaine group was 28.5 kg/m2, and in the control group 26.4 kg/m2. Ropivacaine was discontinued in two patients due to possible toxicity.
An audience member noted that intravenous lidocaine has shown similar benefits in abdominal surgery.
The investigators had no disclosures.
SEATTLE – Intraperitoneal ropivacaine decreases postoperative pain and improves functional recovery after laparoscopic colectomy, according to randomized, blinded trial from the Royal Adelaide (Australia) Hospital.
“We recommend routine inclusion of IPLA [intraperitoneal local anesthetic] in the multimodal analgesia component of ERAS [enhanced-recovery-after-surgery] programs for laparoscopic colectomy,” the investigators concluded.
Recovery was smoother in the ropivacaine group. On a 90-point surgical recovery scale assessing fatigue, mental function, and the ability to do normal daily activities, ropivacaine patients were a few points ahead on days 1 and 3; the gap widened to about 10 points on days 7, 30, and 45. Ropivacaine might have helped reduced inflammation, accounting for the extended benefit, Dr. Lewis said.
Pain control was better with ropivacaine, as well. Ropivacaine patients were about 15-20 points lower on 50-point scales assessing both visceral and abdominal pain at postop hours 3 and 24, and day 7. The findings were statistically significant.
Several trends also favored ropivacaine. Ropivacaine patients had their first bowel movement at around 70 hours postop, versus about 82 hours in the control group. They were also discharged almost a day sooner, and had less postop vomiting. Just one patient in the ropivacaine group was diagnosed with ileus, versus four in the control arm.
There was also a trend for less opioid use in the ropivacaine group, which Dr. Lewis suspected would have been statistically significant if the trial had more patients.
Ropivacaine patients were a mean of 67 years old, versus 62 years old in the control group. There were slightly more men than women in each arm. The mean body mass index in the ropivacaine group was 28.5 kg/m2, and in the control group 26.4 kg/m2. Ropivacaine was discontinued in two patients due to possible toxicity.
An audience member noted that intravenous lidocaine has shown similar benefits in abdominal surgery.
The investigators had no disclosures.
AT ASCRS 2017
Key clinical point:
Major finding: On a 90-point surgical recovery scale assessing fatigue, mental function, and the ability to do normal daily activities, ropivacaine patients were a few points ahead of saline controls on postop days 1 and 3; the gap widened to about 10 points on days 7, 30, and 45.
Data source: Randomized, blinded trial with 51 patients
Disclosures: The investigators had no disclosures.
Proper catheter removal promotes colorectal surgery recovery
Adherence to guidelines for urinary catheter removal significantly reduced rates of urinary tract infection and length of hospital stay, based on data from almost 3,000 patients.
UTIs occurred in 0.8% of colonic surgery patients who were guideline compliant, compared with 4.1% of noncompliant patients. Similarly, UTIs were significantly less likely in rectal surgery patients who complied with guidelines, compared with those who did not (3.5% vs. 9.6%).
The Implementation of the Enhanced Recovery After Surgery (iERAS) program involved 15 academic hospitals in Ontario, Canada. The guidelines include prompt removal of catheters from colonic and rectal surgery patients. Recommended removal times ranged from 24 hours to 72 hours, depending on the procedure.
“Although numerous reports have documented the overall effectiveness of bundled ERAS interventions improving outcome, the contribution of individual components of the pathway in the context of an ERAS implementation program is uncertain,” wrote Allan Okrainec, MD, of the University of Toronto, and his colleagues.
Overall, 53% of patients had catheters removed in compliance with the guidelines, including 47.2% of those with colonic resections and 69.5% of those with rectal resections.
The average length of hospital stay for colonic surgery patients who complied with the urinary catheter guideline was 4 days, compared with 5 days for noncompliant patients, a statistically significant difference. Similarly, the average length of stay was significantly shorter for compliant rectal surgery patients, compared with noncompliant patients (5 days vs. 8 days, respectively).
Reinsertion of the urinary catheter was needed for 6% of the patients, including 122 patients with suspected or confirmed urinary retention and 36 patients who had other indications for reinsertion.
“One of the concerns about early removal of catheters is that it might lead to an increased need for reinsertion,” the researchers noted. “In our study, guideline compliance was associated with an increased rate of catheter reinsertion, but [it] only increased the risk by 2%-3% in patients having rectal or colonic procedures,” the investigators said.
The study results were limited by a lack of information about reasons for noncompliance with the guidelines, the researchers added. However, the data support the value of early catheter removal for surgical patients. “It is noteworthy that, in our study, as well as others, urinary retention rates are relatively low,” they said.
The Council of Academic Hospitals of Ontario funded the study. The researchers had no financial conflicts to disclose.
Adherence to guidelines for urinary catheter removal significantly reduced rates of urinary tract infection and length of hospital stay, based on data from almost 3,000 patients.
UTIs occurred in 0.8% of colonic surgery patients who were guideline compliant, compared with 4.1% of noncompliant patients. Similarly, UTIs were significantly less likely in rectal surgery patients who complied with guidelines, compared with those who did not (3.5% vs. 9.6%).
The Implementation of the Enhanced Recovery After Surgery (iERAS) program involved 15 academic hospitals in Ontario, Canada. The guidelines include prompt removal of catheters from colonic and rectal surgery patients. Recommended removal times ranged from 24 hours to 72 hours, depending on the procedure.
“Although numerous reports have documented the overall effectiveness of bundled ERAS interventions improving outcome, the contribution of individual components of the pathway in the context of an ERAS implementation program is uncertain,” wrote Allan Okrainec, MD, of the University of Toronto, and his colleagues.
Overall, 53% of patients had catheters removed in compliance with the guidelines, including 47.2% of those with colonic resections and 69.5% of those with rectal resections.
The average length of hospital stay for colonic surgery patients who complied with the urinary catheter guideline was 4 days, compared with 5 days for noncompliant patients, a statistically significant difference. Similarly, the average length of stay was significantly shorter for compliant rectal surgery patients, compared with noncompliant patients (5 days vs. 8 days, respectively).
Reinsertion of the urinary catheter was needed for 6% of the patients, including 122 patients with suspected or confirmed urinary retention and 36 patients who had other indications for reinsertion.
“One of the concerns about early removal of catheters is that it might lead to an increased need for reinsertion,” the researchers noted. “In our study, guideline compliance was associated with an increased rate of catheter reinsertion, but [it] only increased the risk by 2%-3% in patients having rectal or colonic procedures,” the investigators said.
The study results were limited by a lack of information about reasons for noncompliance with the guidelines, the researchers added. However, the data support the value of early catheter removal for surgical patients. “It is noteworthy that, in our study, as well as others, urinary retention rates are relatively low,” they said.
The Council of Academic Hospitals of Ontario funded the study. The researchers had no financial conflicts to disclose.
Adherence to guidelines for urinary catheter removal significantly reduced rates of urinary tract infection and length of hospital stay, based on data from almost 3,000 patients.
UTIs occurred in 0.8% of colonic surgery patients who were guideline compliant, compared with 4.1% of noncompliant patients. Similarly, UTIs were significantly less likely in rectal surgery patients who complied with guidelines, compared with those who did not (3.5% vs. 9.6%).
The Implementation of the Enhanced Recovery After Surgery (iERAS) program involved 15 academic hospitals in Ontario, Canada. The guidelines include prompt removal of catheters from colonic and rectal surgery patients. Recommended removal times ranged from 24 hours to 72 hours, depending on the procedure.
“Although numerous reports have documented the overall effectiveness of bundled ERAS interventions improving outcome, the contribution of individual components of the pathway in the context of an ERAS implementation program is uncertain,” wrote Allan Okrainec, MD, of the University of Toronto, and his colleagues.
Overall, 53% of patients had catheters removed in compliance with the guidelines, including 47.2% of those with colonic resections and 69.5% of those with rectal resections.
The average length of hospital stay for colonic surgery patients who complied with the urinary catheter guideline was 4 days, compared with 5 days for noncompliant patients, a statistically significant difference. Similarly, the average length of stay was significantly shorter for compliant rectal surgery patients, compared with noncompliant patients (5 days vs. 8 days, respectively).
Reinsertion of the urinary catheter was needed for 6% of the patients, including 122 patients with suspected or confirmed urinary retention and 36 patients who had other indications for reinsertion.
“One of the concerns about early removal of catheters is that it might lead to an increased need for reinsertion,” the researchers noted. “In our study, guideline compliance was associated with an increased rate of catheter reinsertion, but [it] only increased the risk by 2%-3% in patients having rectal or colonic procedures,” the investigators said.
The study results were limited by a lack of information about reasons for noncompliance with the guidelines, the researchers added. However, the data support the value of early catheter removal for surgical patients. “It is noteworthy that, in our study, as well as others, urinary retention rates are relatively low,” they said.
The Council of Academic Hospitals of Ontario funded the study. The researchers had no financial conflicts to disclose.
FROM THE JOURNAL OF GASTROINTESTINAL SURGERY
Key clinical point: Compliance with guidelines for urinary catheter removal significantly reduced hospital stay and UTI rates in colon and rectal surgery patients.
Major finding: UTI rates in colonic surgery patients were 0.8% and 4.1%, respectively, for those who were compliant and noncompliant with the guidelines. Rates were 3.5% and 9.6%, respectively, for compliant and noncompliant rectal surgery patients.
Data source: A prospective study of 2,927 adults who underwent colonic or rectal surgery between September 2012 and April 2015.
Disclosures: The Council of Academic Hospitals of Ontario funded the study. The researchers had no financial conflicts to disclose.
Sooner is better than later for acute UC surgery
SEATTLE – Postponing surgery for acute ulcerative colitis more than a day increases postoperative complications, lengths of stay, and hospital costs, according to a review by Johns Hopkins University, Baltimore, of almost 2,000 patients.
It’s not uncommon to wait 5 or even 10 days to give biologics a chance to work when patients are admitted for acute ulcerative colitis (UC). Based on the review, however, “we believe that the need for prolonged medical therapy and resuscitation in this patient population prior to colectomy may be overstated,” and that “the lasting effects of persistent inflammation cascade are underestimated.”
The team reviewed 1,953 index UC admissions with emergent non-elective abdominal surgery in the National Inpatient Sample (NIS) database from 2008-13; 546 patients (28%) had early operations - within 24 hours of admission – and the other 1,407 had operations after that time.
Although it’s impossible to say for sure given the limits of administrative data in the NIS, patients who had surgery soon after admission were probably sicker. Even so, they were less likely to have complications than patients in the delayed surgery group (55% versus 43%), and they had shorter hospital stays, with just 8% in the hospital past 21 days, versus 29% of patients who had delayed operations. The findings were similar for both overall length of stay and post-op length of stay.
Renal complications (8% versus 14%), pulmonary complications (20% versus 25%), and thromboembolic events (4% versus 6%) were also less common in the early surgery group. On multivariable analysis, delayed surgery increased the complication rate by 64%.
With fewer complications and shorter hospital stays, early operations were also less expensive, with a mean total hospitalization cost of $19,985 versus $34,258. The findings were all statistically significant.
Dr. Leeds noted the limits of the study; medical management regimes and the reasons for variations in surgical timing are unknown, among other things. “This is not the final answer on what to do with patients like this, but it opens the door to prospective studies that could control” for such variables, he said.
Early surgery patients were more likely to be male (57% versus 51%) and from households with incomes higher than the national median. There were no difference in age, race, comorbidities, region, or hospital type between the two groups.
Dr. Leeds said he had no disclosures.
SEATTLE – Postponing surgery for acute ulcerative colitis more than a day increases postoperative complications, lengths of stay, and hospital costs, according to a review by Johns Hopkins University, Baltimore, of almost 2,000 patients.
It’s not uncommon to wait 5 or even 10 days to give biologics a chance to work when patients are admitted for acute ulcerative colitis (UC). Based on the review, however, “we believe that the need for prolonged medical therapy and resuscitation in this patient population prior to colectomy may be overstated,” and that “the lasting effects of persistent inflammation cascade are underestimated.”
The team reviewed 1,953 index UC admissions with emergent non-elective abdominal surgery in the National Inpatient Sample (NIS) database from 2008-13; 546 patients (28%) had early operations - within 24 hours of admission – and the other 1,407 had operations after that time.
Although it’s impossible to say for sure given the limits of administrative data in the NIS, patients who had surgery soon after admission were probably sicker. Even so, they were less likely to have complications than patients in the delayed surgery group (55% versus 43%), and they had shorter hospital stays, with just 8% in the hospital past 21 days, versus 29% of patients who had delayed operations. The findings were similar for both overall length of stay and post-op length of stay.
Renal complications (8% versus 14%), pulmonary complications (20% versus 25%), and thromboembolic events (4% versus 6%) were also less common in the early surgery group. On multivariable analysis, delayed surgery increased the complication rate by 64%.
With fewer complications and shorter hospital stays, early operations were also less expensive, with a mean total hospitalization cost of $19,985 versus $34,258. The findings were all statistically significant.
Dr. Leeds noted the limits of the study; medical management regimes and the reasons for variations in surgical timing are unknown, among other things. “This is not the final answer on what to do with patients like this, but it opens the door to prospective studies that could control” for such variables, he said.
Early surgery patients were more likely to be male (57% versus 51%) and from households with incomes higher than the national median. There were no difference in age, race, comorbidities, region, or hospital type between the two groups.
Dr. Leeds said he had no disclosures.
SEATTLE – Postponing surgery for acute ulcerative colitis more than a day increases postoperative complications, lengths of stay, and hospital costs, according to a review by Johns Hopkins University, Baltimore, of almost 2,000 patients.
It’s not uncommon to wait 5 or even 10 days to give biologics a chance to work when patients are admitted for acute ulcerative colitis (UC). Based on the review, however, “we believe that the need for prolonged medical therapy and resuscitation in this patient population prior to colectomy may be overstated,” and that “the lasting effects of persistent inflammation cascade are underestimated.”
The team reviewed 1,953 index UC admissions with emergent non-elective abdominal surgery in the National Inpatient Sample (NIS) database from 2008-13; 546 patients (28%) had early operations - within 24 hours of admission – and the other 1,407 had operations after that time.
Although it’s impossible to say for sure given the limits of administrative data in the NIS, patients who had surgery soon after admission were probably sicker. Even so, they were less likely to have complications than patients in the delayed surgery group (55% versus 43%), and they had shorter hospital stays, with just 8% in the hospital past 21 days, versus 29% of patients who had delayed operations. The findings were similar for both overall length of stay and post-op length of stay.
Renal complications (8% versus 14%), pulmonary complications (20% versus 25%), and thromboembolic events (4% versus 6%) were also less common in the early surgery group. On multivariable analysis, delayed surgery increased the complication rate by 64%.
With fewer complications and shorter hospital stays, early operations were also less expensive, with a mean total hospitalization cost of $19,985 versus $34,258. The findings were all statistically significant.
Dr. Leeds noted the limits of the study; medical management regimes and the reasons for variations in surgical timing are unknown, among other things. “This is not the final answer on what to do with patients like this, but it opens the door to prospective studies that could control” for such variables, he said.
Early surgery patients were more likely to be male (57% versus 51%) and from households with incomes higher than the national median. There were no difference in age, race, comorbidities, region, or hospital type between the two groups.
Dr. Leeds said he had no disclosures.
AT ASCRS 2017
Key clinical point:
Major finding: Patients who had surgery soon after admission were probably sicker. Even so, they were less likely to have complications than patients in the delayed surgery group (55% versus 43%), and they had shorter hospital stays, with just 8% in the hospital past 21 days, versus 29% of patients who had delayed operations.
Data source: Review of almost 2,000 patients in the National Inpatient Sample
Disclosures: The lead investigator had no disclosures.
Anal dysplasia surveillance called into question
SEATTLE – Aggressive screening and treatment of HPV anal dysplasia probably doesn’t decrease the incidence of anal cancer, even in high-risk groups, according to investigators from Kaiser Permanente of Southern California.
The increase in anal squamous cell carcinoma (SCC) over the past 20 years has led to surveillance programs for anal dysplasia in many institutions, based on the assumption that finding and destroying the lesions will prevent anal cancer, similar to the reason why polyps are removed during colonoscopy to prevent colon cancer, said lead investigator Marco Tomassi, MD, a general surgeon with Kaiser in San Diego.
Kaiser in Southern California doesn’t have an intensive surveillance program for anal HPV. Instead, high risk patients – those with HIV, past cervical cancer, anogenital warts, among others – are screened with digital rectal exams and anoscopy every 3-12 months, and only anal warts and other grossly abnormal growths are removed.
Physicians there do not routinely use high resolution anoscopy (HRA), Pap smears, and other techniques to identify and destroy microscopic foci of dysplasia, as in more intensive programs.
To see how the approach has worked, Dr. Tomassi and his colleagues reviewed the incidence of anal SCC among almost 6 million Kaiser patients from 2005 through 2015.
The cumulative incidence in all groups of patients, even those at risk for the disease, was less than 1%; 425 of the 460 anal cancers (92%) were in the general population, among patients who would not have been part of a high risk surveillance program.
Even without an aggressive surveillance program, high grade anal dysplasia was identified in 377 patients; their incidence of anal SCC was 0.8%, the highest found in the study.
There were no incident cases of SCC among the 133 HIV patients with anal dysplasia. Among over 5,000 HIV patients in the study, the anal SCC incidence was 0.09%. In the general population of 5.86 million, it was 0.01%.
“The cumulative incidence in our group, despite not performing ablative techniques for dysplasia, was comparable to those institutions that routinely perform high resolution anoscopy and destruction of dysplasia. The low rate of malignant conversion suggests that aggressive surveillance regimens, such as HRA, may lead to unnecessary procedures even in high risk patients,” Dr. Tomassi said.
Intensive surveillance doesn’t seem to make much difference because “the incidence of anal cancer is very low even in very high risk populations,” and “most SCC cases develop in the general population,” so “regimens dedicated to identifying cancer in high risk groups will ultimate miss the majority of patients who will succumb to this disease,” he said.
“It’s rare that I come to a meeting and hear a paper that’s going to change my practice. Thank you for that,” an audience member said after Dr. Tomassi presented his findings at the American Society of Colon and Rectal Surgeons annual meeting.
Dr. Tomassi did not have any disclosures.
SEATTLE – Aggressive screening and treatment of HPV anal dysplasia probably doesn’t decrease the incidence of anal cancer, even in high-risk groups, according to investigators from Kaiser Permanente of Southern California.
The increase in anal squamous cell carcinoma (SCC) over the past 20 years has led to surveillance programs for anal dysplasia in many institutions, based on the assumption that finding and destroying the lesions will prevent anal cancer, similar to the reason why polyps are removed during colonoscopy to prevent colon cancer, said lead investigator Marco Tomassi, MD, a general surgeon with Kaiser in San Diego.
Kaiser in Southern California doesn’t have an intensive surveillance program for anal HPV. Instead, high risk patients – those with HIV, past cervical cancer, anogenital warts, among others – are screened with digital rectal exams and anoscopy every 3-12 months, and only anal warts and other grossly abnormal growths are removed.
Physicians there do not routinely use high resolution anoscopy (HRA), Pap smears, and other techniques to identify and destroy microscopic foci of dysplasia, as in more intensive programs.
To see how the approach has worked, Dr. Tomassi and his colleagues reviewed the incidence of anal SCC among almost 6 million Kaiser patients from 2005 through 2015.
The cumulative incidence in all groups of patients, even those at risk for the disease, was less than 1%; 425 of the 460 anal cancers (92%) were in the general population, among patients who would not have been part of a high risk surveillance program.
Even without an aggressive surveillance program, high grade anal dysplasia was identified in 377 patients; their incidence of anal SCC was 0.8%, the highest found in the study.
There were no incident cases of SCC among the 133 HIV patients with anal dysplasia. Among over 5,000 HIV patients in the study, the anal SCC incidence was 0.09%. In the general population of 5.86 million, it was 0.01%.
“The cumulative incidence in our group, despite not performing ablative techniques for dysplasia, was comparable to those institutions that routinely perform high resolution anoscopy and destruction of dysplasia. The low rate of malignant conversion suggests that aggressive surveillance regimens, such as HRA, may lead to unnecessary procedures even in high risk patients,” Dr. Tomassi said.
Intensive surveillance doesn’t seem to make much difference because “the incidence of anal cancer is very low even in very high risk populations,” and “most SCC cases develop in the general population,” so “regimens dedicated to identifying cancer in high risk groups will ultimate miss the majority of patients who will succumb to this disease,” he said.
“It’s rare that I come to a meeting and hear a paper that’s going to change my practice. Thank you for that,” an audience member said after Dr. Tomassi presented his findings at the American Society of Colon and Rectal Surgeons annual meeting.
Dr. Tomassi did not have any disclosures.
SEATTLE – Aggressive screening and treatment of HPV anal dysplasia probably doesn’t decrease the incidence of anal cancer, even in high-risk groups, according to investigators from Kaiser Permanente of Southern California.
The increase in anal squamous cell carcinoma (SCC) over the past 20 years has led to surveillance programs for anal dysplasia in many institutions, based on the assumption that finding and destroying the lesions will prevent anal cancer, similar to the reason why polyps are removed during colonoscopy to prevent colon cancer, said lead investigator Marco Tomassi, MD, a general surgeon with Kaiser in San Diego.
Kaiser in Southern California doesn’t have an intensive surveillance program for anal HPV. Instead, high risk patients – those with HIV, past cervical cancer, anogenital warts, among others – are screened with digital rectal exams and anoscopy every 3-12 months, and only anal warts and other grossly abnormal growths are removed.
Physicians there do not routinely use high resolution anoscopy (HRA), Pap smears, and other techniques to identify and destroy microscopic foci of dysplasia, as in more intensive programs.
To see how the approach has worked, Dr. Tomassi and his colleagues reviewed the incidence of anal SCC among almost 6 million Kaiser patients from 2005 through 2015.
The cumulative incidence in all groups of patients, even those at risk for the disease, was less than 1%; 425 of the 460 anal cancers (92%) were in the general population, among patients who would not have been part of a high risk surveillance program.
Even without an aggressive surveillance program, high grade anal dysplasia was identified in 377 patients; their incidence of anal SCC was 0.8%, the highest found in the study.
There were no incident cases of SCC among the 133 HIV patients with anal dysplasia. Among over 5,000 HIV patients in the study, the anal SCC incidence was 0.09%. In the general population of 5.86 million, it was 0.01%.
“The cumulative incidence in our group, despite not performing ablative techniques for dysplasia, was comparable to those institutions that routinely perform high resolution anoscopy and destruction of dysplasia. The low rate of malignant conversion suggests that aggressive surveillance regimens, such as HRA, may lead to unnecessary procedures even in high risk patients,” Dr. Tomassi said.
Intensive surveillance doesn’t seem to make much difference because “the incidence of anal cancer is very low even in very high risk populations,” and “most SCC cases develop in the general population,” so “regimens dedicated to identifying cancer in high risk groups will ultimate miss the majority of patients who will succumb to this disease,” he said.
“It’s rare that I come to a meeting and hear a paper that’s going to change my practice. Thank you for that,” an audience member said after Dr. Tomassi presented his findings at the American Society of Colon and Rectal Surgeons annual meeting.
Dr. Tomassi did not have any disclosures.
AT ASCRS 2017
Key clinical point:
Major finding: When high risk patients were not screened and treated for anal dysplasia, the cumulative incidence of anal squamous cell carcinoma was 0.8% or less, similar to programs that target and treat the lesions.
Data source: Review of almost 6 million patients at Kaiser Permanente of Southern California
Disclosures: The lead investigator had no disclosures.
Large-scale ERAS program reduces postoperative LOS, complications
Enhanced Recovery After Surgery (ERAS), a program implemented by Kaiser Permanente Northern California – a multihospital integrated health system – significantly reduced length of stay and complication rates, according to a report published in JAMA Surgery.
Beginning in 2014, when the ERAS program was implemented in 20 Kaiser hospitals, progress was made on the goal of improving inpatient safety, as well as improvements in-hospital mortality, rates of early ambulation, patient nutrition, and reduced opioid use, said Vincent X. Liu, MD, of the division of research, Kaiser Permanente Oakland, and his associates. Those outcomes were studied in the context of a similar group of patients in other, non-ERAS hospitals to determine the degree of change in each area.
ERAS aimed to reduce opioid use by encouraging multimodal analgesia, which included pre- and postoperative IV acetaminophen and NSAIDs, perioperative IV lidocaine, or peripheral nerve blocks. It encouraged ambulation within 12 hours of surgery completion and a daily goal of walking at least 21 feet during the first 3 postoperative days.
The program enhanced patient nutrition by reducing prolonged preoperative fasting, providing a high-carbohydrate beverage 2-4 hours before surgery, and allowing solids 8-12 hours before surgery. It also provided food within 12 hours of completing surgery. ERAS also encouraged patient engagement in care by use of educational materials and a calendar that detailed what the care process would entail. For clinicians, ERAS provided new electronic tools such as electronic medical record order sets to facilitate standardized practice.
In the first phase of their study, Dr. Liu and his associates assessed changes over time in patient safety outcomes among 3,768 patients undergoing elective colorectal resection and 5,002 undergoing emergency hip fracture repair.
Hospital length of stay decreased significantly after implementation of ERAS, from 5.1 to 4.2 days in the colorectal resection group and from 3.6 to 3.2 days in the hip fracture group. Complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively. Early ambulation rates increased substantially, from 22.3% to 56.5% and from 2.8% to 21.2%, respectively.
The rate of improved nutrition rose from 13.0% to 39.2% in the colorectal resection group and from 45.6% to 57.1% in the hip repair group. And the total dose of morphine equivalents dropped from 52.4 to 30.6 and from 38.9 to 27.0, respectively (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1032).
In the second phase of the study, the investigators compared these changes against the outcomes of two comparator groups who underwent similar surgeries (5,556 resection comparators and 1,523 hip repair comparators) during the same time frame but in hospitals that did not implement the ERAS program.
In this analysis, LOS was significantly shorter and complication rates were significantly lower for both procedures at the hospitals where the intervention was implemented, compared with the other hospitals. In-hospital mortality, opioid use, early ambulation, and discharge to home rather than a rehabilitation facility also favored the intervention groups.
“This study demonstrates the effectiveness of a systems-level approach to ERAS program implementation, even across widely divergent target populations,” Dr. Liu and his associates said.
The Gordon and Betty Moore Foundation, the Permanente Medical Group, the Kaiser Foundation Health Plan, and the National Institutes of Health funded the study. Dr. Liu and his associates reported having no relevant financial disclosures.
Findings from Liu et al. have clinical, research, and policy relevance. First, they went beyond select surgical procedures from single hospitals. The investigators have robustly taken implementation science to the next level, thus showing that thoughtfully planned quality-improvement endeavors that are integrated with robust research evaluation measures can positively affect our surgical patients. In a similar vein, these results underscore the value proposition of research conducted in large health care systems that goes beyond the limitation of traditional stand-alone hospitals, such as small sample size and referral and practice biases. [In addition,] this investigation raises many and exciting future research opportunities to an eager audience of stakeholders. What are the cost implications of such efforts? How can we better leverage electronic health records with smart tools to better implement and measure the effects of the ERAS program and other quality and safety initiatives? [We also] need to be mindful of its unintended consequences on vulnerable populations and financially strained hospitals.
Mohammed Bayasi, MD, FACS, and Waddah Al-Refaie, MD, FACS, are with the department of surgery, MedStar Georgetown University Hospital, Washington. Their comments are from an editorial (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1051). They had no disclosures.
Findings from Liu et al. have clinical, research, and policy relevance. First, they went beyond select surgical procedures from single hospitals. The investigators have robustly taken implementation science to the next level, thus showing that thoughtfully planned quality-improvement endeavors that are integrated with robust research evaluation measures can positively affect our surgical patients. In a similar vein, these results underscore the value proposition of research conducted in large health care systems that goes beyond the limitation of traditional stand-alone hospitals, such as small sample size and referral and practice biases. [In addition,] this investigation raises many and exciting future research opportunities to an eager audience of stakeholders. What are the cost implications of such efforts? How can we better leverage electronic health records with smart tools to better implement and measure the effects of the ERAS program and other quality and safety initiatives? [We also] need to be mindful of its unintended consequences on vulnerable populations and financially strained hospitals.
Mohammed Bayasi, MD, FACS, and Waddah Al-Refaie, MD, FACS, are with the department of surgery, MedStar Georgetown University Hospital, Washington. Their comments are from an editorial (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1051). They had no disclosures.
Findings from Liu et al. have clinical, research, and policy relevance. First, they went beyond select surgical procedures from single hospitals. The investigators have robustly taken implementation science to the next level, thus showing that thoughtfully planned quality-improvement endeavors that are integrated with robust research evaluation measures can positively affect our surgical patients. In a similar vein, these results underscore the value proposition of research conducted in large health care systems that goes beyond the limitation of traditional stand-alone hospitals, such as small sample size and referral and practice biases. [In addition,] this investigation raises many and exciting future research opportunities to an eager audience of stakeholders. What are the cost implications of such efforts? How can we better leverage electronic health records with smart tools to better implement and measure the effects of the ERAS program and other quality and safety initiatives? [We also] need to be mindful of its unintended consequences on vulnerable populations and financially strained hospitals.
Mohammed Bayasi, MD, FACS, and Waddah Al-Refaie, MD, FACS, are with the department of surgery, MedStar Georgetown University Hospital, Washington. Their comments are from an editorial (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1051). They had no disclosures.
Enhanced Recovery After Surgery (ERAS), a program implemented by Kaiser Permanente Northern California – a multihospital integrated health system – significantly reduced length of stay and complication rates, according to a report published in JAMA Surgery.
Beginning in 2014, when the ERAS program was implemented in 20 Kaiser hospitals, progress was made on the goal of improving inpatient safety, as well as improvements in-hospital mortality, rates of early ambulation, patient nutrition, and reduced opioid use, said Vincent X. Liu, MD, of the division of research, Kaiser Permanente Oakland, and his associates. Those outcomes were studied in the context of a similar group of patients in other, non-ERAS hospitals to determine the degree of change in each area.
ERAS aimed to reduce opioid use by encouraging multimodal analgesia, which included pre- and postoperative IV acetaminophen and NSAIDs, perioperative IV lidocaine, or peripheral nerve blocks. It encouraged ambulation within 12 hours of surgery completion and a daily goal of walking at least 21 feet during the first 3 postoperative days.
The program enhanced patient nutrition by reducing prolonged preoperative fasting, providing a high-carbohydrate beverage 2-4 hours before surgery, and allowing solids 8-12 hours before surgery. It also provided food within 12 hours of completing surgery. ERAS also encouraged patient engagement in care by use of educational materials and a calendar that detailed what the care process would entail. For clinicians, ERAS provided new electronic tools such as electronic medical record order sets to facilitate standardized practice.
In the first phase of their study, Dr. Liu and his associates assessed changes over time in patient safety outcomes among 3,768 patients undergoing elective colorectal resection and 5,002 undergoing emergency hip fracture repair.
Hospital length of stay decreased significantly after implementation of ERAS, from 5.1 to 4.2 days in the colorectal resection group and from 3.6 to 3.2 days in the hip fracture group. Complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively. Early ambulation rates increased substantially, from 22.3% to 56.5% and from 2.8% to 21.2%, respectively.
The rate of improved nutrition rose from 13.0% to 39.2% in the colorectal resection group and from 45.6% to 57.1% in the hip repair group. And the total dose of morphine equivalents dropped from 52.4 to 30.6 and from 38.9 to 27.0, respectively (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1032).
In the second phase of the study, the investigators compared these changes against the outcomes of two comparator groups who underwent similar surgeries (5,556 resection comparators and 1,523 hip repair comparators) during the same time frame but in hospitals that did not implement the ERAS program.
In this analysis, LOS was significantly shorter and complication rates were significantly lower for both procedures at the hospitals where the intervention was implemented, compared with the other hospitals. In-hospital mortality, opioid use, early ambulation, and discharge to home rather than a rehabilitation facility also favored the intervention groups.
“This study demonstrates the effectiveness of a systems-level approach to ERAS program implementation, even across widely divergent target populations,” Dr. Liu and his associates said.
The Gordon and Betty Moore Foundation, the Permanente Medical Group, the Kaiser Foundation Health Plan, and the National Institutes of Health funded the study. Dr. Liu and his associates reported having no relevant financial disclosures.
Enhanced Recovery After Surgery (ERAS), a program implemented by Kaiser Permanente Northern California – a multihospital integrated health system – significantly reduced length of stay and complication rates, according to a report published in JAMA Surgery.
Beginning in 2014, when the ERAS program was implemented in 20 Kaiser hospitals, progress was made on the goal of improving inpatient safety, as well as improvements in-hospital mortality, rates of early ambulation, patient nutrition, and reduced opioid use, said Vincent X. Liu, MD, of the division of research, Kaiser Permanente Oakland, and his associates. Those outcomes were studied in the context of a similar group of patients in other, non-ERAS hospitals to determine the degree of change in each area.
ERAS aimed to reduce opioid use by encouraging multimodal analgesia, which included pre- and postoperative IV acetaminophen and NSAIDs, perioperative IV lidocaine, or peripheral nerve blocks. It encouraged ambulation within 12 hours of surgery completion and a daily goal of walking at least 21 feet during the first 3 postoperative days.
The program enhanced patient nutrition by reducing prolonged preoperative fasting, providing a high-carbohydrate beverage 2-4 hours before surgery, and allowing solids 8-12 hours before surgery. It also provided food within 12 hours of completing surgery. ERAS also encouraged patient engagement in care by use of educational materials and a calendar that detailed what the care process would entail. For clinicians, ERAS provided new electronic tools such as electronic medical record order sets to facilitate standardized practice.
In the first phase of their study, Dr. Liu and his associates assessed changes over time in patient safety outcomes among 3,768 patients undergoing elective colorectal resection and 5,002 undergoing emergency hip fracture repair.
Hospital length of stay decreased significantly after implementation of ERAS, from 5.1 to 4.2 days in the colorectal resection group and from 3.6 to 3.2 days in the hip fracture group. Complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively. Early ambulation rates increased substantially, from 22.3% to 56.5% and from 2.8% to 21.2%, respectively.
The rate of improved nutrition rose from 13.0% to 39.2% in the colorectal resection group and from 45.6% to 57.1% in the hip repair group. And the total dose of morphine equivalents dropped from 52.4 to 30.6 and from 38.9 to 27.0, respectively (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1032).
In the second phase of the study, the investigators compared these changes against the outcomes of two comparator groups who underwent similar surgeries (5,556 resection comparators and 1,523 hip repair comparators) during the same time frame but in hospitals that did not implement the ERAS program.
In this analysis, LOS was significantly shorter and complication rates were significantly lower for both procedures at the hospitals where the intervention was implemented, compared with the other hospitals. In-hospital mortality, opioid use, early ambulation, and discharge to home rather than a rehabilitation facility also favored the intervention groups.
“This study demonstrates the effectiveness of a systems-level approach to ERAS program implementation, even across widely divergent target populations,” Dr. Liu and his associates said.
The Gordon and Betty Moore Foundation, the Permanente Medical Group, the Kaiser Foundation Health Plan, and the National Institutes of Health funded the study. Dr. Liu and his associates reported having no relevant financial disclosures.
FROM JAMA SURGERY
Key clinical point: An Enhanced Recovery After Surgery program aimed at improving inpatient safety significantly reduced length of stay and complication rates at 20 California hospitals.
Major finding: After the ERAS program was implemented, hospital LOS decreased from 5.1 to 4.2 days in the colorectal resection group and from 3.6 to 3.2 days in the hip fracture group, and complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively.
Data source: A “pre-post” comparison study of patients’ safety outcomes after implementation of an ERAS program, which involved 15,849 surgical patients at 20 hospitals.
Disclosures: The Gordon and Betty Moore Foundation, the Permanente Medical Group, the Kaiser Foundation Health Plan, and the National Institutes of Health funded the study. Dr. Liu and his associates reported having no relevant financial disclosures.
It Pays to Get Screened for Colon Cancer
Although cancer death rates have been decreasing for the general population, they’ve been increasing for American Indians, according to the American Indian Cancer Foundation (AICAF). The AICAF cites a number of barriers to prevention and care, such as low awareness of risks, distrust of medical systems and research, health beliefs that may conflict with prevention practices, and low awareness of screening options.
The Northern Plains region has some of the highest rates of cancer diagnoses and death in the U.S. Colon cancer, for example, is 53% higher in Northern Plains American Indians, AICAF says. Although screening rates are improving, fewer than half of Northern Plains American Indians aged ≥ 50 years have had a colorectal cancer screening, according to the Association of American Indian Physicians.
The cancer mortality rates are the result of a “complex set of factors” that the AICAF is beginning to address with a comprehensive set of approaches. For instance, in addition to educating the public, AICAF, in partnership with the Minnesota Department of Health and Get Your Rear in Gear Colon Cancer Coalition is putting money where its mouth is, with the “Refer-a-Relative” program.
“We are all related,” the campaign says: “Help your community and end colon cancer!” Refer-a-Relative encourages Native Americans in the Minneapolis-St. Paul metropolitan area to get screened, and then to refer up to 5 relatives aged ≥ 50 years for screening. Patients receive a $20 gift card for completing screening, and $10 for each relative who completes screening. The relatives receive a $20 gift card and can refer more people.
The screening project is 1 branch of the AICAF’s interest in innovating clinical systems at IHS, Tribal, and Urban (ITU) clinics. Much of the work is based on the Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) project with ITU clinics. The AICAF invites interested ITU clinics to join the Clinical Cancer Screening Network. For more information, infographics, and other patient education materials, visit www.americanindiancancer.org.
Although cancer death rates have been decreasing for the general population, they’ve been increasing for American Indians, according to the American Indian Cancer Foundation (AICAF). The AICAF cites a number of barriers to prevention and care, such as low awareness of risks, distrust of medical systems and research, health beliefs that may conflict with prevention practices, and low awareness of screening options.
The Northern Plains region has some of the highest rates of cancer diagnoses and death in the U.S. Colon cancer, for example, is 53% higher in Northern Plains American Indians, AICAF says. Although screening rates are improving, fewer than half of Northern Plains American Indians aged ≥ 50 years have had a colorectal cancer screening, according to the Association of American Indian Physicians.
The cancer mortality rates are the result of a “complex set of factors” that the AICAF is beginning to address with a comprehensive set of approaches. For instance, in addition to educating the public, AICAF, in partnership with the Minnesota Department of Health and Get Your Rear in Gear Colon Cancer Coalition is putting money where its mouth is, with the “Refer-a-Relative” program.
“We are all related,” the campaign says: “Help your community and end colon cancer!” Refer-a-Relative encourages Native Americans in the Minneapolis-St. Paul metropolitan area to get screened, and then to refer up to 5 relatives aged ≥ 50 years for screening. Patients receive a $20 gift card for completing screening, and $10 for each relative who completes screening. The relatives receive a $20 gift card and can refer more people.
The screening project is 1 branch of the AICAF’s interest in innovating clinical systems at IHS, Tribal, and Urban (ITU) clinics. Much of the work is based on the Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) project with ITU clinics. The AICAF invites interested ITU clinics to join the Clinical Cancer Screening Network. For more information, infographics, and other patient education materials, visit www.americanindiancancer.org.
Although cancer death rates have been decreasing for the general population, they’ve been increasing for American Indians, according to the American Indian Cancer Foundation (AICAF). The AICAF cites a number of barriers to prevention and care, such as low awareness of risks, distrust of medical systems and research, health beliefs that may conflict with prevention practices, and low awareness of screening options.
The Northern Plains region has some of the highest rates of cancer diagnoses and death in the U.S. Colon cancer, for example, is 53% higher in Northern Plains American Indians, AICAF says. Although screening rates are improving, fewer than half of Northern Plains American Indians aged ≥ 50 years have had a colorectal cancer screening, according to the Association of American Indian Physicians.
The cancer mortality rates are the result of a “complex set of factors” that the AICAF is beginning to address with a comprehensive set of approaches. For instance, in addition to educating the public, AICAF, in partnership with the Minnesota Department of Health and Get Your Rear in Gear Colon Cancer Coalition is putting money where its mouth is, with the “Refer-a-Relative” program.
“We are all related,” the campaign says: “Help your community and end colon cancer!” Refer-a-Relative encourages Native Americans in the Minneapolis-St. Paul metropolitan area to get screened, and then to refer up to 5 relatives aged ≥ 50 years for screening. Patients receive a $20 gift card for completing screening, and $10 for each relative who completes screening. The relatives receive a $20 gift card and can refer more people.
The screening project is 1 branch of the AICAF’s interest in innovating clinical systems at IHS, Tribal, and Urban (ITU) clinics. Much of the work is based on the Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) project with ITU clinics. The AICAF invites interested ITU clinics to join the Clinical Cancer Screening Network. For more information, infographics, and other patient education materials, visit www.americanindiancancer.org.
Novel robotic camera photographs colon
A novel robotically driven capsule successfully navigated a colon in a pig model in 100% of 30 retroflexion maneuvers, setting the stage for further study of robotics in colonoscopy. The data were presented at the annual Digestive Disease Week.
Although capsule technology has expanded exploration of the GI tract, current capsules are limited by passive movement and lack therapeutic capability, said Keith L. Obstein, MD, of Vanderbilt University in Nashville, Tenn.
The researchers developed a capsule with an 18-mm head and interior permanent magnets designed to be automatically controlled by an external robotic arm in difficult areas.
“Retroflexion is a common but mechanically complex maneuver during colonoscopy, and therefore serves as an excellent subject for autonomous control,” the researchers noted.
Logistically, the capsule is soft-tethered after it is introduced through the rectum, which allows the potential for therapeutic procedures such as biopsies and polyp removal. In addition, the use of an external magnet to pull the robot with the tether may reduce the pressure on the colon that typically created when a physician pushes the colonoscope from behind. Therefore, use of a robotic capsule may help reduce patients’ discomfort and make them more amenable to the procedure, Dr. Obstein said.
In the study, an endoscopist performed the first retroflexion with a standard colonoscope at 15 cm from the anal sphincter, and these parameters were used to set the robotic system for autonomous retroflexion at 15 cm from the anal sphincter.
The success rate was 100% for both the standard endoscope and the automatically controlled robot for each of 30 maneuvers. The average time for a robotic maneuver was 12 seconds, and no leaks or histologic abnormalities were noted.
Studies to evaluate additional control algorithms are in progress, and the robot capsule may be ready for human trials in 2018, Dr. Obstein said.
This study was supported by the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health under award number R01EB018992. Dr. Obstein had no relevant financial conflicts to disclose.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Surgery of the Alimentary Tract (SSAT).
A novel robotically driven capsule successfully navigated a colon in a pig model in 100% of 30 retroflexion maneuvers, setting the stage for further study of robotics in colonoscopy. The data were presented at the annual Digestive Disease Week.
Although capsule technology has expanded exploration of the GI tract, current capsules are limited by passive movement and lack therapeutic capability, said Keith L. Obstein, MD, of Vanderbilt University in Nashville, Tenn.
The researchers developed a capsule with an 18-mm head and interior permanent magnets designed to be automatically controlled by an external robotic arm in difficult areas.
“Retroflexion is a common but mechanically complex maneuver during colonoscopy, and therefore serves as an excellent subject for autonomous control,” the researchers noted.
Logistically, the capsule is soft-tethered after it is introduced through the rectum, which allows the potential for therapeutic procedures such as biopsies and polyp removal. In addition, the use of an external magnet to pull the robot with the tether may reduce the pressure on the colon that typically created when a physician pushes the colonoscope from behind. Therefore, use of a robotic capsule may help reduce patients’ discomfort and make them more amenable to the procedure, Dr. Obstein said.
In the study, an endoscopist performed the first retroflexion with a standard colonoscope at 15 cm from the anal sphincter, and these parameters were used to set the robotic system for autonomous retroflexion at 15 cm from the anal sphincter.
The success rate was 100% for both the standard endoscope and the automatically controlled robot for each of 30 maneuvers. The average time for a robotic maneuver was 12 seconds, and no leaks or histologic abnormalities were noted.
Studies to evaluate additional control algorithms are in progress, and the robot capsule may be ready for human trials in 2018, Dr. Obstein said.
This study was supported by the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health under award number R01EB018992. Dr. Obstein had no relevant financial conflicts to disclose.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Surgery of the Alimentary Tract (SSAT).
A novel robotically driven capsule successfully navigated a colon in a pig model in 100% of 30 retroflexion maneuvers, setting the stage for further study of robotics in colonoscopy. The data were presented at the annual Digestive Disease Week.
Although capsule technology has expanded exploration of the GI tract, current capsules are limited by passive movement and lack therapeutic capability, said Keith L. Obstein, MD, of Vanderbilt University in Nashville, Tenn.
The researchers developed a capsule with an 18-mm head and interior permanent magnets designed to be automatically controlled by an external robotic arm in difficult areas.
“Retroflexion is a common but mechanically complex maneuver during colonoscopy, and therefore serves as an excellent subject for autonomous control,” the researchers noted.
Logistically, the capsule is soft-tethered after it is introduced through the rectum, which allows the potential for therapeutic procedures such as biopsies and polyp removal. In addition, the use of an external magnet to pull the robot with the tether may reduce the pressure on the colon that typically created when a physician pushes the colonoscope from behind. Therefore, use of a robotic capsule may help reduce patients’ discomfort and make them more amenable to the procedure, Dr. Obstein said.
In the study, an endoscopist performed the first retroflexion with a standard colonoscope at 15 cm from the anal sphincter, and these parameters were used to set the robotic system for autonomous retroflexion at 15 cm from the anal sphincter.
The success rate was 100% for both the standard endoscope and the automatically controlled robot for each of 30 maneuvers. The average time for a robotic maneuver was 12 seconds, and no leaks or histologic abnormalities were noted.
Studies to evaluate additional control algorithms are in progress, and the robot capsule may be ready for human trials in 2018, Dr. Obstein said.
This study was supported by the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health under award number R01EB018992. Dr. Obstein had no relevant financial conflicts to disclose.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Surgery of the Alimentary Tract (SSAT).
FROM DDW
Key clinical point: An 18-mm magnetized capsule colonoscope successfully navigated a pig colon, and researchers are planning human trials for 2018.
Major finding: An automated robot capsule successfully completed 30 retroflexion maneuvers in a pig colon with an average time of 12 seconds.
Data source: The data come from a test of 30 maneuvers.
Disclosures: This study was supported by the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health under award number R01EB018992. Dr. Obstein had no relevant financial conflicts to disclose.
Study Reveals Tumor Blood Vessels Cluster in Beltlike Zones
Digital pathology has made it possible to measure microscopic objects, such as blood vessels in tumor tissue and then visualize them in density maps, showing hotspot regions. But for many applications in histopathology, there is no clear-cut definition of the hotspots, say researchers from Heidelberg University in Germany. Thus, most tumor models “implicitly assume” that blood vessels are equally abundant in different parts of a tumor. But the researchers’ new computational approach to mapping angiogenesis in colorectal cancer (CRC) could change that assumption.
Related: In Rare Case Colorectal Cancer Causes Thrombus
Their method analyzes blood vessels based on spatial statistics, identifying all hotspot areas that are unlikely to occur by chance. The researchers found that in nearly all cases, the blood vessels grouped in a distinctive beltlike pattern. In 33 of 34 untreated colorectal tumor samples, the blood vessels were aggregated at the interface of tumor tissue to the intestinal wall. The researchers found similar “hypervascularized” zones at the boundaries of liver tissue in 100% of the samples of CRC liver metastases. Ultimately, they describe a new model of tumor vascularization: a highly vascularized zone about 1.5-mm wide close to the intestinal lumen in CRC primary tumors and a highly vascularized zone approximately 1-mm wide close to the invasion front in CRC liver metastases.
Related: Colorectal Screening: Available but Underused
Their model has immediate and far-reaching implications, the researchers say. For instance, because vascular patterns determine how chemotherapeutic drugs are distributed in tumor tissue, it is likely that these drugs reach the luminal side of CRC tumors much easier than they reach the the basolateral side. Their new information also could be used in timing surgery, since the tumor parts of the deep invasion front may be less sensitive to chemotherapy. The researchers suggest that using their model could help optimize treatment in any number of ways: explaining early symptoms like gastrointestinal bleeding, the architecture of CRC, metastasis, and opening new pathways for investigation.
Source:
Kather JN, Zöllner FG, Schad LR. PLoS One. 2017;12(3):e0171378.
doi: 10.1371/journal.pone.0171378.
Digital pathology has made it possible to measure microscopic objects, such as blood vessels in tumor tissue and then visualize them in density maps, showing hotspot regions. But for many applications in histopathology, there is no clear-cut definition of the hotspots, say researchers from Heidelberg University in Germany. Thus, most tumor models “implicitly assume” that blood vessels are equally abundant in different parts of a tumor. But the researchers’ new computational approach to mapping angiogenesis in colorectal cancer (CRC) could change that assumption.
Related: In Rare Case Colorectal Cancer Causes Thrombus
Their method analyzes blood vessels based on spatial statistics, identifying all hotspot areas that are unlikely to occur by chance. The researchers found that in nearly all cases, the blood vessels grouped in a distinctive beltlike pattern. In 33 of 34 untreated colorectal tumor samples, the blood vessels were aggregated at the interface of tumor tissue to the intestinal wall. The researchers found similar “hypervascularized” zones at the boundaries of liver tissue in 100% of the samples of CRC liver metastases. Ultimately, they describe a new model of tumor vascularization: a highly vascularized zone about 1.5-mm wide close to the intestinal lumen in CRC primary tumors and a highly vascularized zone approximately 1-mm wide close to the invasion front in CRC liver metastases.
Related: Colorectal Screening: Available but Underused
Their model has immediate and far-reaching implications, the researchers say. For instance, because vascular patterns determine how chemotherapeutic drugs are distributed in tumor tissue, it is likely that these drugs reach the luminal side of CRC tumors much easier than they reach the the basolateral side. Their new information also could be used in timing surgery, since the tumor parts of the deep invasion front may be less sensitive to chemotherapy. The researchers suggest that using their model could help optimize treatment in any number of ways: explaining early symptoms like gastrointestinal bleeding, the architecture of CRC, metastasis, and opening new pathways for investigation.
Source:
Kather JN, Zöllner FG, Schad LR. PLoS One. 2017;12(3):e0171378.
doi: 10.1371/journal.pone.0171378.
Digital pathology has made it possible to measure microscopic objects, such as blood vessels in tumor tissue and then visualize them in density maps, showing hotspot regions. But for many applications in histopathology, there is no clear-cut definition of the hotspots, say researchers from Heidelberg University in Germany. Thus, most tumor models “implicitly assume” that blood vessels are equally abundant in different parts of a tumor. But the researchers’ new computational approach to mapping angiogenesis in colorectal cancer (CRC) could change that assumption.
Related: In Rare Case Colorectal Cancer Causes Thrombus
Their method analyzes blood vessels based on spatial statistics, identifying all hotspot areas that are unlikely to occur by chance. The researchers found that in nearly all cases, the blood vessels grouped in a distinctive beltlike pattern. In 33 of 34 untreated colorectal tumor samples, the blood vessels were aggregated at the interface of tumor tissue to the intestinal wall. The researchers found similar “hypervascularized” zones at the boundaries of liver tissue in 100% of the samples of CRC liver metastases. Ultimately, they describe a new model of tumor vascularization: a highly vascularized zone about 1.5-mm wide close to the intestinal lumen in CRC primary tumors and a highly vascularized zone approximately 1-mm wide close to the invasion front in CRC liver metastases.
Related: Colorectal Screening: Available but Underused
Their model has immediate and far-reaching implications, the researchers say. For instance, because vascular patterns determine how chemotherapeutic drugs are distributed in tumor tissue, it is likely that these drugs reach the luminal side of CRC tumors much easier than they reach the the basolateral side. Their new information also could be used in timing surgery, since the tumor parts of the deep invasion front may be less sensitive to chemotherapy. The researchers suggest that using their model could help optimize treatment in any number of ways: explaining early symptoms like gastrointestinal bleeding, the architecture of CRC, metastasis, and opening new pathways for investigation.
Source:
Kather JN, Zöllner FG, Schad LR. PLoS One. 2017;12(3):e0171378.
doi: 10.1371/journal.pone.0171378.
In Rare Case Colorectal Cancer Causes Thrombus
A 46-year-old woman went to her family doctor after 3 months of abdominal bloating, fatigue, nausea, vomiting, anorexia, and weight loss. Ultrasound imaging revealed hepatic lesions and a mass in the colon; she was diagnosed with colon cancer. The cancer had metastasized to an extent that complete resection wasn’t possible, so she received palliative-intent therapy for the next 18 months.
Related: Colorectal Screening: Available but Underused
Initially, the patient responded to the treatment but then presented to the emergency department (ED) with a severe headache. A CT scan revealed that the cancer had spread to her brain. However, this time resection was possible, and she recovered well.
Three weeks later the patient was back in the ED with an infection. A new CT scan showed no evidence of abscess (one of the differential diagnoses). A transthoracic echocardiogram showed a right atrial lesion, and further imaging confirmed a lesion in the right atrium. “Unexpectedly,” her clinicians reported, the lesion originated from the distal inferior vena cava (IVC): She had shown no signs of symptoms of pulmonary embolus or occlusion of the IVC.
Tumor thrombus is rarely reported with colorectal cancer cases, so the patient’s clinicians at first thought the mass in the IVC was bland thrombus, managed with anticoagulation alone. The clinicians felt that the assumption was reasonable, given the link between malignancy and venous thromboembolism; also because the patient had an indwelling central venous catheter. Contrast-enhanced CT scan and contrast-enhanced ultrasound, however, supported the diagnosis of tumor thrombus.
Due to the rarity of tumor thrombus in colorectal cancer, there are no guidelines for diagnosis and management, the clinicians say. In the patient’s case, consultation with cardiologists, radiologists, and gastrointestinal specialists at the cancer center resulted in an offer to extract the thrombus, but the risks and the fact that she was asymptomatic led the patient to decline. She was instead restarted on palliative chemotherapy with heparin in case part of the thrombus was indeed bland thrombus.
The patient’s condition deteriorated over the next 3 months. She and her team agreed that supportive care at home was best. The patient still had no symptoms from the tumor thrombus when she died.
Related: Cancer Prevention and Gastrointestinal Risk
Autopsy supported the suspicion that the original lesion was partly tumor thrombus and partly bland thrombus, reduced by anticoagulation. But autopsy results revealed no embolization of tumor thrombus or bland thrombus into the pulmonary arteries, although there were extensive metastases in the brain, lung, liver, adrenals, and ovaries. Ultimately, the patient’s death was attributed not to the tumor thrombus that extended into the right atrium but to multiorgan failure due to cancer--validating the decisions to not choose surgery for the thrombus.
Source:
Meyers D, Nixon NA, Franko A, Ng D, Tam VC. BMJ Case Rep. 2017;2017:pii:bcr2016218107.
doi: 10.1136/bcr-2016-218107.
A 46-year-old woman went to her family doctor after 3 months of abdominal bloating, fatigue, nausea, vomiting, anorexia, and weight loss. Ultrasound imaging revealed hepatic lesions and a mass in the colon; she was diagnosed with colon cancer. The cancer had metastasized to an extent that complete resection wasn’t possible, so she received palliative-intent therapy for the next 18 months.
Related: Colorectal Screening: Available but Underused
Initially, the patient responded to the treatment but then presented to the emergency department (ED) with a severe headache. A CT scan revealed that the cancer had spread to her brain. However, this time resection was possible, and she recovered well.
Three weeks later the patient was back in the ED with an infection. A new CT scan showed no evidence of abscess (one of the differential diagnoses). A transthoracic echocardiogram showed a right atrial lesion, and further imaging confirmed a lesion in the right atrium. “Unexpectedly,” her clinicians reported, the lesion originated from the distal inferior vena cava (IVC): She had shown no signs of symptoms of pulmonary embolus or occlusion of the IVC.
Tumor thrombus is rarely reported with colorectal cancer cases, so the patient’s clinicians at first thought the mass in the IVC was bland thrombus, managed with anticoagulation alone. The clinicians felt that the assumption was reasonable, given the link between malignancy and venous thromboembolism; also because the patient had an indwelling central venous catheter. Contrast-enhanced CT scan and contrast-enhanced ultrasound, however, supported the diagnosis of tumor thrombus.
Due to the rarity of tumor thrombus in colorectal cancer, there are no guidelines for diagnosis and management, the clinicians say. In the patient’s case, consultation with cardiologists, radiologists, and gastrointestinal specialists at the cancer center resulted in an offer to extract the thrombus, but the risks and the fact that she was asymptomatic led the patient to decline. She was instead restarted on palliative chemotherapy with heparin in case part of the thrombus was indeed bland thrombus.
The patient’s condition deteriorated over the next 3 months. She and her team agreed that supportive care at home was best. The patient still had no symptoms from the tumor thrombus when she died.
Related: Cancer Prevention and Gastrointestinal Risk
Autopsy supported the suspicion that the original lesion was partly tumor thrombus and partly bland thrombus, reduced by anticoagulation. But autopsy results revealed no embolization of tumor thrombus or bland thrombus into the pulmonary arteries, although there were extensive metastases in the brain, lung, liver, adrenals, and ovaries. Ultimately, the patient’s death was attributed not to the tumor thrombus that extended into the right atrium but to multiorgan failure due to cancer--validating the decisions to not choose surgery for the thrombus.
Source:
Meyers D, Nixon NA, Franko A, Ng D, Tam VC. BMJ Case Rep. 2017;2017:pii:bcr2016218107.
doi: 10.1136/bcr-2016-218107.
A 46-year-old woman went to her family doctor after 3 months of abdominal bloating, fatigue, nausea, vomiting, anorexia, and weight loss. Ultrasound imaging revealed hepatic lesions and a mass in the colon; she was diagnosed with colon cancer. The cancer had metastasized to an extent that complete resection wasn’t possible, so she received palliative-intent therapy for the next 18 months.
Related: Colorectal Screening: Available but Underused
Initially, the patient responded to the treatment but then presented to the emergency department (ED) with a severe headache. A CT scan revealed that the cancer had spread to her brain. However, this time resection was possible, and she recovered well.
Three weeks later the patient was back in the ED with an infection. A new CT scan showed no evidence of abscess (one of the differential diagnoses). A transthoracic echocardiogram showed a right atrial lesion, and further imaging confirmed a lesion in the right atrium. “Unexpectedly,” her clinicians reported, the lesion originated from the distal inferior vena cava (IVC): She had shown no signs of symptoms of pulmonary embolus or occlusion of the IVC.
Tumor thrombus is rarely reported with colorectal cancer cases, so the patient’s clinicians at first thought the mass in the IVC was bland thrombus, managed with anticoagulation alone. The clinicians felt that the assumption was reasonable, given the link between malignancy and venous thromboembolism; also because the patient had an indwelling central venous catheter. Contrast-enhanced CT scan and contrast-enhanced ultrasound, however, supported the diagnosis of tumor thrombus.
Due to the rarity of tumor thrombus in colorectal cancer, there are no guidelines for diagnosis and management, the clinicians say. In the patient’s case, consultation with cardiologists, radiologists, and gastrointestinal specialists at the cancer center resulted in an offer to extract the thrombus, but the risks and the fact that she was asymptomatic led the patient to decline. She was instead restarted on palliative chemotherapy with heparin in case part of the thrombus was indeed bland thrombus.
The patient’s condition deteriorated over the next 3 months. She and her team agreed that supportive care at home was best. The patient still had no symptoms from the tumor thrombus when she died.
Related: Cancer Prevention and Gastrointestinal Risk
Autopsy supported the suspicion that the original lesion was partly tumor thrombus and partly bland thrombus, reduced by anticoagulation. But autopsy results revealed no embolization of tumor thrombus or bland thrombus into the pulmonary arteries, although there were extensive metastases in the brain, lung, liver, adrenals, and ovaries. Ultimately, the patient’s death was attributed not to the tumor thrombus that extended into the right atrium but to multiorgan failure due to cancer--validating the decisions to not choose surgery for the thrombus.
Source:
Meyers D, Nixon NA, Franko A, Ng D, Tam VC. BMJ Case Rep. 2017;2017:pii:bcr2016218107.
doi: 10.1136/bcr-2016-218107.
Transanal TME comparable to open, lap approaches to rectal cancer
HOUSTON – Transanal total mesorectal excision can consistently achieve good pathological results for obtaining specimens in rectal cancer, and overcome the shortcomings of the open and laparoscopic approaches to rectal cancer surgery, particularly in the distal part of the rectum where obtaining quality specimens can be technically challenging, researchers at the Hospital Clinic of Barcelona have found.
Reporting at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Jacqueline van Laarhoven, MD, PhD, said, “Pathologically, transanal total mesorectal excision [TME] provides good results on integrity of the mesorectum, negative circumferential and distal resection margins, and lymph nodes per specimen.” This study represents the first results of a relatively large, single-institution cohort, Dr. van Laarhoven said.
The study involved 187 patients with mid- or low-rectal cancer who had transanal TME from November 2011 to June 2016. Dr. van Laarhoven explained that obtaining high-quality specimens is an important prognostic factor for determining locoregional recurrence in rectal cancer. The study analyzed results of excised specimens in the mesorectum, circumferential and distal resected margins, and lymph nodes, and compared outcomes with those in two randomized clinical trials of both open and laparoscopic TME – the COLOR II (Lancet Oncol. 2013;14:210-8) and COREAN trials (Lancet Oncol. 2014;15:767-74) – where applicable.
In the Barcelona study population, 63.1% had tumors in the midrectum and 36.9% in the low rectum. Transanal TME yielded complete mesorectal quality in 95.7% of cases, almost-complete quality in 1.6% and incomplete in 1.1%, but comparison with COLOR II and COREAN trials was difficult because of differing inclusion criteria, Dr. van Laarhoven said.
Mean distal margin was 2.1 cm in midrectal cancer with a positive distal resection margin in 3.2%. In low-rectal cancer, the mean distal margin was 1.1 cm with a positive distal resection margin in 7.8%. Dr. van Laarhoven noted the overall circumferential resection margin (CRM) was 8.6% in this study, compared with 8.3% overall for the COREAN trial. As for COLOR II, the overall rate for positive CRM in mid- and low-rectal tumors was around 9%, Dr. van Laarhoven said, but in the open group the positive CRM was 3% in the midrectal excisions and 22% in low-rectal disease.
With regard to lymph nodes, the Barcelona study reported a median of 14 per specimen, with a range of 11 to 18, Dr. van Laarhoven said. However, in nonirradiated patients, the median was 15 per specimen. “This is consistent with the fact that neoadjuvant radiotherapy leads to a decrease in the lymph-node harvest,” she said. “These results are comparable to the COREAN and the COLOR II trials.”
Sixty-two percent of patients received neoadjuvant chemoradiotherapy, 3.2% received radiotherapy only, and 2.1% chemotherapy only.
On preoperative staging, 3.2% had T1 tumors, 20.3% T2, 67.9% T3, and 7.5% T4. The overall positive CRM (less than 1 mm) was 8.6% (including T4 tumors).
Postoperative pathological staging showed complete remission in 16% of patients, pT1 in 6.4%, pT2 in 28.9%, pT3 in 42.8%, pT4 in 2.7%, and pTis in 1.6%.
Dr. van Laarhoven commented, “As the quality of the surgical treatment is a surrogate marker for survival, transanal TME can be regarded as an oncologically safe method to treat patients with rectal cancer.”
Dr. van Laarhoven reported having no financial disclosures.
HOUSTON – Transanal total mesorectal excision can consistently achieve good pathological results for obtaining specimens in rectal cancer, and overcome the shortcomings of the open and laparoscopic approaches to rectal cancer surgery, particularly in the distal part of the rectum where obtaining quality specimens can be technically challenging, researchers at the Hospital Clinic of Barcelona have found.
Reporting at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Jacqueline van Laarhoven, MD, PhD, said, “Pathologically, transanal total mesorectal excision [TME] provides good results on integrity of the mesorectum, negative circumferential and distal resection margins, and lymph nodes per specimen.” This study represents the first results of a relatively large, single-institution cohort, Dr. van Laarhoven said.
The study involved 187 patients with mid- or low-rectal cancer who had transanal TME from November 2011 to June 2016. Dr. van Laarhoven explained that obtaining high-quality specimens is an important prognostic factor for determining locoregional recurrence in rectal cancer. The study analyzed results of excised specimens in the mesorectum, circumferential and distal resected margins, and lymph nodes, and compared outcomes with those in two randomized clinical trials of both open and laparoscopic TME – the COLOR II (Lancet Oncol. 2013;14:210-8) and COREAN trials (Lancet Oncol. 2014;15:767-74) – where applicable.
In the Barcelona study population, 63.1% had tumors in the midrectum and 36.9% in the low rectum. Transanal TME yielded complete mesorectal quality in 95.7% of cases, almost-complete quality in 1.6% and incomplete in 1.1%, but comparison with COLOR II and COREAN trials was difficult because of differing inclusion criteria, Dr. van Laarhoven said.
Mean distal margin was 2.1 cm in midrectal cancer with a positive distal resection margin in 3.2%. In low-rectal cancer, the mean distal margin was 1.1 cm with a positive distal resection margin in 7.8%. Dr. van Laarhoven noted the overall circumferential resection margin (CRM) was 8.6% in this study, compared with 8.3% overall for the COREAN trial. As for COLOR II, the overall rate for positive CRM in mid- and low-rectal tumors was around 9%, Dr. van Laarhoven said, but in the open group the positive CRM was 3% in the midrectal excisions and 22% in low-rectal disease.
With regard to lymph nodes, the Barcelona study reported a median of 14 per specimen, with a range of 11 to 18, Dr. van Laarhoven said. However, in nonirradiated patients, the median was 15 per specimen. “This is consistent with the fact that neoadjuvant radiotherapy leads to a decrease in the lymph-node harvest,” she said. “These results are comparable to the COREAN and the COLOR II trials.”
Sixty-two percent of patients received neoadjuvant chemoradiotherapy, 3.2% received radiotherapy only, and 2.1% chemotherapy only.
On preoperative staging, 3.2% had T1 tumors, 20.3% T2, 67.9% T3, and 7.5% T4. The overall positive CRM (less than 1 mm) was 8.6% (including T4 tumors).
Postoperative pathological staging showed complete remission in 16% of patients, pT1 in 6.4%, pT2 in 28.9%, pT3 in 42.8%, pT4 in 2.7%, and pTis in 1.6%.
Dr. van Laarhoven commented, “As the quality of the surgical treatment is a surrogate marker for survival, transanal TME can be regarded as an oncologically safe method to treat patients with rectal cancer.”
Dr. van Laarhoven reported having no financial disclosures.
HOUSTON – Transanal total mesorectal excision can consistently achieve good pathological results for obtaining specimens in rectal cancer, and overcome the shortcomings of the open and laparoscopic approaches to rectal cancer surgery, particularly in the distal part of the rectum where obtaining quality specimens can be technically challenging, researchers at the Hospital Clinic of Barcelona have found.
Reporting at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Jacqueline van Laarhoven, MD, PhD, said, “Pathologically, transanal total mesorectal excision [TME] provides good results on integrity of the mesorectum, negative circumferential and distal resection margins, and lymph nodes per specimen.” This study represents the first results of a relatively large, single-institution cohort, Dr. van Laarhoven said.
The study involved 187 patients with mid- or low-rectal cancer who had transanal TME from November 2011 to June 2016. Dr. van Laarhoven explained that obtaining high-quality specimens is an important prognostic factor for determining locoregional recurrence in rectal cancer. The study analyzed results of excised specimens in the mesorectum, circumferential and distal resected margins, and lymph nodes, and compared outcomes with those in two randomized clinical trials of both open and laparoscopic TME – the COLOR II (Lancet Oncol. 2013;14:210-8) and COREAN trials (Lancet Oncol. 2014;15:767-74) – where applicable.
In the Barcelona study population, 63.1% had tumors in the midrectum and 36.9% in the low rectum. Transanal TME yielded complete mesorectal quality in 95.7% of cases, almost-complete quality in 1.6% and incomplete in 1.1%, but comparison with COLOR II and COREAN trials was difficult because of differing inclusion criteria, Dr. van Laarhoven said.
Mean distal margin was 2.1 cm in midrectal cancer with a positive distal resection margin in 3.2%. In low-rectal cancer, the mean distal margin was 1.1 cm with a positive distal resection margin in 7.8%. Dr. van Laarhoven noted the overall circumferential resection margin (CRM) was 8.6% in this study, compared with 8.3% overall for the COREAN trial. As for COLOR II, the overall rate for positive CRM in mid- and low-rectal tumors was around 9%, Dr. van Laarhoven said, but in the open group the positive CRM was 3% in the midrectal excisions and 22% in low-rectal disease.
With regard to lymph nodes, the Barcelona study reported a median of 14 per specimen, with a range of 11 to 18, Dr. van Laarhoven said. However, in nonirradiated patients, the median was 15 per specimen. “This is consistent with the fact that neoadjuvant radiotherapy leads to a decrease in the lymph-node harvest,” she said. “These results are comparable to the COREAN and the COLOR II trials.”
Sixty-two percent of patients received neoadjuvant chemoradiotherapy, 3.2% received radiotherapy only, and 2.1% chemotherapy only.
On preoperative staging, 3.2% had T1 tumors, 20.3% T2, 67.9% T3, and 7.5% T4. The overall positive CRM (less than 1 mm) was 8.6% (including T4 tumors).
Postoperative pathological staging showed complete remission in 16% of patients, pT1 in 6.4%, pT2 in 28.9%, pT3 in 42.8%, pT4 in 2.7%, and pTis in 1.6%.
Dr. van Laarhoven commented, “As the quality of the surgical treatment is a surrogate marker for survival, transanal TME can be regarded as an oncologically safe method to treat patients with rectal cancer.”
Dr. van Laarhoven reported having no financial disclosures.
AT SAGES 2017
Key clinical point: Transanal total mesorectal excision (TME) is a viable alternative to open or laparoscopic TME in cancers of the low and midrectum.
Major finding: Postoperative pathological staging showed complete remission in 16%, with pT1 in 6.4%, pT2 in 28.9%, pT3 in 42.8%, pT4 in 2.7%, and pTis in 1.6%.
Data source: Analysis of 187 patients prospectively enrolled in a standardized database who had transanal TME from November 2011 to June 2016 at a single center.
Disclosures: Dr. van Laarhoven reported having no financial disclosures.