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Purpose Treatment of invasive rectal adenocarcinoma is stratified into upfront surgery versus neoadjuvant chemoradiotherapy, in part, based on tumor distance from the anal verge (AV). This study examines the correlation between tumor distance measurements (endoscopic and MRI) and relationship to the anterior peritoneal reflection (APR) on MRI. Methods A single-center retrospective study was performed at a tertiary center accredited by the National Accreditation Program for Rectal Cancer (NAPRC). 162 patients with invasive rectal cancer were seen between October of 2018 and April of 2022. Sensitivity and specificity were determined for MRI and endoscopic measurements in their ability to predict tumor location relative to the APR. Results 119 patients had tumors endoscopically and radiographically measured from the AV. Pelvic MRI characterized tumors as above (intraperitoneal) or at/straddles/below the APR (extraperitoneal). True positives were defined as extraperitoneal tumors 10cm. Endoscopy was 81.9% sensitive and 64.3% specific in predicting tumor location with respect to the APR. MRI was 86.7% sensitive and 92.9% specific. Utilizing a 12cm cutoff, sensitivity of both modalities increased (94.3%, 91.4%) but specificity decreased (50%, 64.3%). Conclusion For locally invasive rectal cancers, tumor position relative to the APR is an important factor in determining the role of neoadjuvant therapy. These results suggest endoscopic tumor measurements do not accurately predict tumor location relative to the APR, and may lead to incorrect treatment stratification. When the APR is not identified, MRI-reported tumor distance may be a better predictor of this relationship.

Rectal small cell carcinoma is a rare and aggressive cancer subtype for which a consensus of optimal treatment has not yet been reached. This cancer presents a difficult surgical problem, and thus, the mainstay of treatment tends to mirror that of small cell carcinoma of the lung (chemotherapy, radiation therapy, and immune modulators). This brief report highlights current treatment options available for this rare and difficult entity. There is a significant need for large-center clinical trials and prospective studies to help determine the best treatment regimen to effectively care for patients with small cell carcinoma of the rectum.

Survival for patients with locally advanced esophageal cancer remains dismal. Non-response to neoadjuvant chemoradiation (nCRT) portends worse survival. We hypothesized that patients undergoing up-front esophagectomy may have better survival than those who do not respond to nCRT. We identified all patients undergoing esophagectomy with a pathologic stage of II or greater at our institution between 1994 and 2015 and separated them into two groups: those who received nCRT and those undergoing up-front esophagectomy. The neoadjuvant group was further separated into patients downstaged to pathologic stage 0 or I (responders) and patients with either the same or higher pathologic stage after nCRT, or with pathologic stage II disease or greater (non-responders). Overall survival was compared between groups using Kaplan–Meier statistics. Covariate-adjusted Cox modeling was used to estimate hazard ratios (HR) for mortality associated with non-response. Overall, 287 patients met inclusion criteria. Fifty-nine percent of the responders had pathologic complete response (pCR). The majority of non-responders and primary esophagectomy patients had stage II or III disease (94%). Median survival was 58.3 months in responders, 23.9 months in non-responders, and 29.1 months in primary esophagectomy patients (p

Background Anastomotic strictures represent a major source of morbidity in colorectal surgery with an incidence reported up to 30%. Despite this, the mechanism by which strictures develop remains unclear. This study aims to determine the incidence of colorectal anastomotic strictures and associated risk factors among a series of diverted patients. Materials and Methods A retrospective chart review was conducted of 142 patients over a 7-year period at a single institution after colorectal resection with anastomosis and diverting ileostomy creation re-examined with postoperative endoscopy. One patient was removed due to anastomotic tumor recurrence. Patient and technical factors were examined for significance using chi-square analysis. Logistic regression was used to perform multivariate analysis to estimate odds ratio (OR) and 95% confidence intervals (CI). Results Among 141 patients, 14.1% (20 patients) developed strictures detected on endoscopy. Strictures were observed in a greater percentage of women than men (21.2% vs 8%, P = .025). 30.6% of patients who underwent resections for diverticulitis developed strictures while those with neoplastic lesions and other indications had stricture rates of 6.8% and 17.6%, respectively ( P = .002). Anastomoses performed during a colostomy reversal were associated with a higher stricture rate (OR 4.23, 95% CI 1.37-13.40, P = .012). Anastomoses performed with a 28/29 mm EEA circular stapler demonstrated a significantly higher stricture rate versus a 31/33 mm stapler (OR 7.21, 95% CI 1.23-155.58, P = .045). Discussion Our data reveal that female sex, history of diverticulitis, anastomoses performed in the setting of colostomy reversal, and smaller stapler size are associated with a higher rate of anastomotic stricture.

The Siewert classification system for gastroesophageal junction adenocarcinoma has provided morphological and topographical information to help guide surgical decision-making. Evidence has shown that Siewert I and III tumors are distinct entities with differing epidemiologic and histologic characteristics and distinct patterns of disease progression, requiring different treatment. Siewert II tumors share some of the characteristics of type I and III lesions, and the surgical approach is not universally agreed upon. Appropriate surgical options include transthoracic esophagogastrectomy, transhiatal esophagectomy, and transabdominal extended total gastrectomy. A review of the available evidence of the surgical management of Siewert II tumors is presented. Careful review of the data appear to support the fact that a satisfactory oncologic resection can be achieved via a transabdominal extended total gastrectomy with a slight advantage in terms of perioperative complications, and overall postoperative quality of life. Overall and disease-free survival compares favorably to the transthoracic approach. These results can be achieved with careful selection of patients balancing more than just the Siewert type in the decision-making but considering also preoperative T and N stages, histological type (diffuse type requiring longer margins that are not always achievable via gastrectomy), and the presence of Barrett’s esophagus.

The effects of neoadjuvant chemoradiation therapy on lymph node retrieval during esophagectomy for patients with esophageal cancer are unclear. The aim of this study was to quantify lymph node retrieval after R0 esophagectomy and to assess its impact on overall survival in induction therapy patients. One hundred seventy-four consecutive patients underwent esophagectomy with or without induction therapy from 2008 to 2015 for esophageal cancer. Total lymph nodes, positive lymph nodes, and lymph node ratios were compared between two groups of patients: those treated with either upfront surgery or those treated with neoadjuvant chemoradiation therapy followed by surgery. Comparisons were made using Student’s t test. Overall survival was obtained and compared using Kaplan Meier survival curves. Total lymph node counts were less in the induction therapy group (p = 0.027), while positive lymph node counts and lymph node ratios did not differ between groups (p = 0.262 and p = 0.310, respectively). In the neoadjuvant chemoradiation followed by surgery group, overall survival was significantly shorter for patients who had any positive lymph nodes in the pathologic specimen (p = 0.0065). Total lymph node counts were significantly lower in the induction therapy group, while positive lymph node counts and lymph node ratios did not differ from the upfront surgery group. Although overall survival was not different between groups, it was decreased within the induction therapy cohort among those who had any positive lymph nodes retrieved at surgery. This study confirms that unstratified gross lymph node counts do not substantially relate to prognosis in the heterogeneous population of locally advanced esophageal cancer patients who may or may not have had neoadjuvant chemoradiation.

Background Esophagectomy carries considerable morbidity. Many studies have evaluated factors to predict patients at risk. This study aimed to determine whether the surgical Apgar score (SAS) predicts complications and length of stay (LOS) for patients undergoing esophagectomy. Study Design We evaluated 212 patients undergoing esophagectomy. Postoperative complications were graded using the Clavien-Dindo scale and the SAS was determined. Association of SAS with incidence of complications was evaluated using the Cochran-Armitage trend test between grouped SAS scores (0-2, 3-4, 5-6, 7-8, 9-10) and each of the outcomes. Correlation of SAS with LOS was evaluated using competing risks proportional hazards regression. Results The average patient age was 63.5 years (range 31-86), and the average blood loss was 284 mL (range 50-4000). The median LOS was 10 days. There was a significant association between SAS and grade 2 or higher (P = 0.0002) and grade 3 or higher (P

Patients with inflammatory bowel disease (IBD) will often require abdominal surgical intervention for indications not directly related to their IBD. Because these patients often have a history of multiple previous abdominal operations and/or ostomies, they are at increased risk for incisional and parastomal hernias. They may also have develop symptomatic cholelithiasis, chronic pain, or desmoid disease. All of these potentially surgical issues may require special consideration in the IBD population.

Intraoperative pyloric procedures are often performed during esophagectomies to reduce the rates of gastric conduit dysfunction. They include pyloroplasty (PP), pyloromyotomy (PM), and pylorus botulinum toxin type-A injections (BI). Despite these procedures, patients frequently warrant further endoscopic interventions. The aim of this study is to compare intraoperative pyloric procedures and the rates of postoperative endoscopic interventions following minimally invasive esophagectomy (MIE). We identified patients who underwent MIE for esophageal carcinoma and grouped them as 'None' (no intervention), 'PP', 'PM', or 'BI' based on intraoperative pyloric procedure type. The rates of endoscopic interventions for the first six postoperative months were compared. To adjust for variability due to MIE type, the rates of1 interventions were compared using a zero-inflated Poisson regression analysis. Significance was established at P0.05. There were 146 patients who underwent an MIE for esophageal cancer from 2008 to 2015; 77.4% were three-hole MIE, and 22.6% were Ivor- Lewis MIE. BI was most frequent in Ivor-Lewis patients (63.5%), while PP was most frequent (46.9%) in three-hole patients. Postoperative endoscopic interventions occurred in 38 patients (26.0%). The BI group had the highest percentage of patients requiring a postoperative intervention (n = 13, 31.7%). After adjusting for higher rates of interventions in three-hole MIE patients, the BI and None groups had the lowest rates of1 postoperative interventions. Our data did not show superiority of any pyloric intervention in preventing endoscopic interventions. The patients who received BI to the pylorus demonstrated a trend toward a greater likelihood of having a postoperative intervention. However when adjusted for type of MIE, the BI and None groups had lower rates of subsequent multiple interventions. Further research is needed to determine if the choice of intraoperative pyloric procedure type significantly affects quality of life, morbidity, and overall prognosis in these patients.

Since the introduction of minimally invasive esophagectomy 25 years ago, its use has been reported in several high volume centers. With only one published randomized control trial and five meta-analyses comparing its outcomes to open esophagectomy, available level I evidence is very limited. Available technical approaches include total minimally invasive transthoracic (Ivor Lewis or McKeown) or transhiatal esophagectomy; several hybrid options are available with one portion of the procedure completed via an open approach. A review of available level I evidence with focus on total minimally invasive esophagectomy is presented. The old debate regarding the superiority of a transthoracic versus transhiatal approach to esophagectomy may have been settled by minimally invasive esophagectomy as only few centers are reporting on the latter being utilized. The studies with the highest level of evidence available currently show that minimally invasive techniques via a transthoracic approach are associated with less overall morbidity, fewer pulmonary complications, and shorter hospital stays than open esophagectomy. There appears to be no detrimental effect on oncologic outcomes and possibly an added benefit derived by improved lymph node retrieval. Quality of life improvements may also translate into improved survival, but no conclusive evidence exists to support this claim. Robotic and hybrid techniques have also been implemented, but there currently is no evidence showing that these are superior to other minimally invasive techniques.