Recommended reading: Board picks the ‘best of 2018’

Colorectal Surgery

Cercek A et al. Adoption of total neoadjuvant therapy for locally advanced rectal cancer. JAMA Oncol. 2018;4(6):e180071. doi:10.1001/jamaoncol.2018.0071.

This moderate sized retrospective study demonstrates a single-institution’s experience with total neoadjuvant therapy (TNT) with chemoradiation and chemotherapy as opposed to traditional chemoradiation, surgery, and chemotherapy in patients with locally advanced rectal cancer. They demonstrate equivalent or potentially better outcomes including better complete response rate – 36% versus 21% and rates of chemotherapy completion. While further studies are needed to understand long term outcomes, this study support the use of TNT for locally advanced rectal cancer as now supported by the National Comprehensive Cancer Network guidelines.

 

Brouquet A et al. Anti-TNF therapy is associated with an increased risk of postoperative morbidity after surgery for ileocolonic Crohn disease: Results of a prospective nationwide cohort. Ann Surg. 2018 Feb;267(2):221-228. doi: 10.1097/SLA.0000000000002017. 

This large prospective study of almost 600 consecutive Crohn’s disease patients with surgery at 19 French specialty centers demonstrates that anti-TNF therapy less than 3 months prior to ileocolic surgery to be an independent risk factor of the overall postoperative morbidity, preoperative hemoglobin less than10 g/dL, operative time more than180 min, and recurrent Crohn’s disease, as well as a higher risk of overall and intra-abdominal septic postoperative morbidities.

Howard R et al. Taking control of your surgery: Impact of a prehabilitation program on major abdominal surgery. J Am Coll Surg. 2018 Oct 22; https://doi.org/10.1016/j.jamcollsurg.2018.09.018

Results from the Michigan Surgical and Health Optimization Program (MSHOP) are reported in colectomy patients. This prehabilitation program engages patients in four activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. MSHOP patients were matched to emergency and elective, non-MSHOP patients. Overall, 70% of MSHOP patients complied with the program. MSHOP patients were more likely to have improved blood pressure and heart rate intraoperatively, reduction in Clavien-Dindo class 3-4 complications in the MSHOP group (30%), compared with the nonprehabilitation (38%) and emergency (48%) groups (P = .05), as well as average savings of $21,946 per patient.

Genevieve Melton-Meaux, MD, PhD, FACS

Bariatric Surgery

Kalff MC et al. Diagnostic value of computed tomography for detecting anastomotic or staple line leakage after bariatric surgery. Surg Obes Relat Dis. 2018;14(9):1310-16

The most dreaded complication in the current era of metabolic and bariatric surgery, from a technical point of view, remains an anastomotic or staple-line leak. The authors present their findings corresponding to a multivariable regression analysis of a retrospective review of all CT abdomen and pelvis scans conducted from November 2007 to August 2016 at their large teaching hospital and Bariatric Center of Excellence. A CT is especially useful at ruling out low-suspicion cases of leaks, when the surgeon is trying to decide if a diagnostic laparoscopy is indicated, with a sensitivity of 90%-100%, and a negative predictive value of 97%-100%. A negative CT scan is highly accurate for ruling out a leak, especially in those patients without co-existing tachycardia and tachypnea. With caution based on clinical expertise, it may serve to prevent unnecessary diagnostic laparoscopy when appropriately indicated.
 

Alizadeh RF et al. Risk factors for gastrointestinal leak after bariatric surgery: MBSAQIP analysis. J Am Coll Surg. 2018;227(1):135-141.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 database of accredited centers was the object of study. Multivariate logistic regression analysis was used to examine risk factors for GI leaks that are not typically included in similar studies. Of particular interest is finding that Roux-en-Y gastric bypass comes with a higher risk for leak, compared with a sleeve gastrectomy, but with an overall leak rate for both of 0.7% based on current results. In addition, the study found that use of an intraoperative provocative leak test and placement of a surgical drain are associated with a higher leak rate. The same is not true of a postoperative swallow contrast study, which has no effect on the incidence of leaks.

Altieri MS et al. Evaluation of VTE prophylaxis and the impact of alternate regimens on post-operative bleeding and thrombotic complications following bariatric procedures. Surg Endosc. 2018;32(12):4805-4812.

The field of venous thromboembolism prevention after bariatric surgery remains a challenging one due to the lack of consensus among surgeons. This study analyzes the Cerner Health Facts database from 2003 to 2013, particularly with ICD-9 codes, for patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy. While the authors confirm the statement that there is a lack of consistency and, therefore, there is ample variability among bariatric centers and surgeons, the use of postoperative VTE chemoprophylaxis leads to a lower incidence of VTE events, and less frequent bleeding episodes, compared with pre-operative chemoprophylaxis. Finally, mixed therapy using heparin and enoxaparin led to more bleeding complications and blood transfusion requirements.

Rodolfo J. Oviedo, MD, FACS, FASMBS