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Background Anal SCC is a rare disease mainly treated with chemoradiation. Abdominoperineal resection (APR), once the mainstay of treatment for anal cancer, now serves a role as salvage therapy for persistent or recurrent disease after chemoradiation. In addition, clinically positive nodes are currently treated by extending the radiation field to the groin. The role of inguinal lymph node dissection in recurrent or persistent anal SCC is unclear. The aim of the study is to determine the role of inguinal lymph node dissection in the management of inguinal lymph node metastasis for anal squamous cell carcinoma (SCC). Methods Retrospective analysis of patients with anal SCC in the National Cancer Database with positive inguinal nodes undergoing salvage APR between 2004 and 2014 was performed. A comparison of overall survival between patients who underwent APR with lymph node dissection versus APR only was analyzed using Kaplan-Meier plot. Results A total of 3424 patients underwent salvage APR, with 274 (8%) having clinically positive nodes. Within the subgroup that had clinically positive nodes, 195 (71%) underwent APR, whereas 79 (29%) underwent both APR and node dissection. Kaplan-Meier analysis demonstrates no difference in overall survival in the two groups (P = 0.99). Five-year survival for both groups was similar (36% versus 42%; P = 0.987). No significant difference was found when adjusted for age, gender, and Tumor Node Metastasis staging. Conclusions Inguinal lymph node dissection does not appear to improve overall survival in patients with advanced-stage anal cancer requiring salvage APR. Proper patient selection for node dissection is essential to spare patients from additional morbid procedures.

Colon cancer is the third leading cause of cancer-related deaths. Although there have been numerous advancements in treatment options, electing to undergo surgery is a difficult decision, and some patients may be hesitant to undergo surgery. We sought to understand the risk factors associated with refusal of surgery and predictors of mortality in patients with colon cancer. We retrospectively reviewed the Surveillance, Epidemiology, and End Results database for patients diagnosed with colon cancer from 1995 to 2015. We stratified patients according to whether they underwent surgery or refused recommended surgery. We analyzed numerous demographic, surgical, and oncologic variables and performed univariate analysis to assess predictors for refusal of surgery as well as survival and mortality risk in those refusing surgery. Our analysis included 288,322 patients with primary colon cancer where 284,591 (98.7%) underwent cancer-direct surgery and 3731 (1.3%) refused recommended surgery. Those refusing cancer directed surgery were more likely to be > 70 years old, non-Hispanic black patients, and have distant staged cancer (all p

Background Anastomotic leakage remains a dreaded complication after colorectal surgery. Stem-cell-based therapies have been shown to increase angiogenesis and cell proliferation. Objective The purpose of this research was to investigate the use of adipose-derived stem cells on the healing of ischemic colonic anastomoses in a rat model. Design This is an animal research study using xenotransplantation. Settings Male Wistar rats (300-400 g, n = 48) were purchased from a licensed breeder. Patients Adipose stem cells were isolated from the subcutaneous fat of healthy human donors. Interventions The rats underwent laparotomy with creation of an ischemic colorectal anastomosis created by ligation of mesenteric vessels. The animals were divided into 3 groups: control group with an ischemic anastomosis, vehicle-only group in which the ischemic anastomosis was treated with an absorbable gelatin sponge, and a treatment group in which the ischemic anastomosis was treated with an absorbable gelatin sponge plus adipose stem cells. Animals were killed at postoperative days 3 and 7. Main outcome measures Anastomotic leakage was defined as the finding of feculent peritonitis or perianastomotic abscess on necropsy. Rat mRNA expression was measured using real-time polymerase chain reaction. Results Adipose-derived stem cells significantly decreased anastomotic leakage when compared with control at both postoperative days 3 (25.0% vs 87.5%; p = 0.02) and 7 (25.0% vs 87.5%; p = 0.02). The use of an absorbable gelatin sponge alone had no effect on anastomotic leakage when compared with control and postoperative days 3 or 7. We found that stem cell-treated animals had a 5.9-fold and 7.4-fold increase in the expression of vascular endothelial growth factor when compared with control at 3 and 7 days; however, this difference was not statistically significant when compared with the absorbable gelatin sponge group. Limitations This is a preclinical animal research study using xenotransplantation of cultured stem cells. Conclusions Locally transplanted adipose stem cells enhance the healing of ischemic colorectal anastomoses and may be a novel strategy for reducing the risk of anastomotic leakage in colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B203. EL TRANSPLANTE LOCAL DE CELULAS MADRE ADIPOSAS REDUCE LA FUGA ANASTOMOTICA EN LAS SUTURAS COLORRECTALES ISQUEMICAS: MODELO EN RATAS: Las fugas anastomoticas son una complicacion pusilanime despues de toda cirugia colorrectal. Se ha demostrado que el tratamiento con celulas madre aumenta la angiogenesis y la proliferacion celular.Investigar el uso de celulas madre derivadas de tejido adiposo en la cicatrizacion de una anastomosis colonica isquemica basada en ratas como modelo.Estudio de investigacion en animales utilizando xenotrasplantes.Adquisicion de tipicas ratas de laboratorio raza Wistar, todas machos (300-400 g, n = 48) de un criadero autorizado.Aislamiento de celulas madre de tipo adiposo del tejido celular subcutaneo en donantes humanos sanos.Las ratas se sometieron a laparotomia con la creacion de una anastomosis colorrectal isquemica obtenida mediante ligadura controlada de los vasos mesentericos correspondientes. Los animales se dividieron en tres grupos: grupo de control con anastomosis isquemica, grupo de vehiculo unico en el que la anastomosis isquemica se trato con una esponja de gelatina absorbible, y un grupo de tratamiento en el que la anastomosis isquemica se trato con una esponja de gelatina absorbible asociada a un vastago adiposo de celulas madre. Los animales fueron sacrificados el POD3 y el POD7.La fuga anastomotica fue definida como el hallazgo de peritonitis fecaloidea o absceso perianastomotico a la necropsia. La expresion de RNAm de las ratas se midio usando PCR en tiempo real.Las celulas madre derivadas de tejido adiposo disminuyeron significativamente la fuga anastomotica en comparacion con el grupo control tanto en el POD3 (25% frente a 87.5%, p = 0.02) como en el POD7 (25% frente a 87.5%, p = 0.02). El uso de una esponja de gelatina absorbible sola, no tuvo efecto sobre la fuga anastomotica en comparacion con los controles el POD3 o el POD7. Descubrimos que los animales tratados con celulas madre adiposas tenian un aumento de 5,9 y 7,4 veces en la expresion de VEGF en comparacion con el control a los 3 y 7 dias, respectivamente; sin embargo, esta diferencia no fue estadisticamente significativa en comparacion con el grupo de esponja de gelatina absorbible.Este es un estudio preclinico de investigacion en animales que utiliza xenotrasplantes de celulas madre adiposas cultivadas.Las celulas madre de tipo adiposo trasplantadas localmente mejoran la cicatrisacion en casos de anastomosis colorrectales isquemicas, y podrian convertirse en una nueva estrategia para reducir el riesgo de fugas anastomoticas en casos de cirugia colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B203. (Traduccion-Dr Xavier Delgadillo).

Fluid management within Enhanced Recovery After Surgery (ERAS) protocols is designed to maintain a euvolemic state avoiding the negative sequelae of hypervolemia or hypovolemia. We sought to determine the effect of a recent ERAS protocol implementation on kidney function and on the incidence of postoperative acute kidney injury (AKI). A total of 132 elective colorectal resections performed using our ERAS protocol were compared to a propensity-matched group prior to ERAS implementation. Fluid balance, urine output, creatinine, and blood urea nitrogen (BUN) were recorded for all patients, and the incidence of AKI was determined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Implementation of our ERAS protocol decreased average postoperative length of hospital stay (5.5 vs 7.7 days, p

Lynch syndrome (LS) is a hereditary condition that increases one’s risk of developing colorectal, endometrial, and other extracolonic cancers. MD Anderson Cancer Center at Cooper implemented a reflex screening protocol for DNA mismatch repair (dMMR) deficiency. Those with findings suspicious for LS were referred for genetic counseling (GC). Our goal was to assess compliance with GC and factors associated with successful follow-up. Immunohistochemistry (IHC) for the MMR proteins MSH2, MLH1, MSH6, and PMS2 was performed on all colorectal tumor resections from patients ≤70 years old and all stage II cancers. Tumors with loss of MLH1/PMS2 were subsequently tested for BRAF mutation or MLH1 promoter methylation to identify tumors with likely epigenetic inactivation of MLH1. Patients with loss of MLH1/PMS2 without BRAF mutations or with absence of MLH1 promoter methylation and those with loss of MSH2/MSH6 were referred to GC. Compliance with GC was assessed. Between March 2014 and August 2016, 203 tumors were tested by IHC. Fifteen (7.4%) patients had abnormal MMR protein expression patterns in the absence of BRAF mutation or MLH1 promoter methylation suggestive of possible LS. GC compliance was 35.7% overall and 85.7% in those with family history of LS-associated cancers. Overall, GC compliance was relatively low in our study. Interestingly, patients with a strong family history of LS-associated neoplasms were more likely to pursue GC. In the future, assessing and addressing barriers to seeking GC will provide opportunities to improve patient care through increased identification of patients with cancer predisposition syndromes.

The construction of an intestinal stoma is fraught with complications and should not be considered a trivial undertaking. Serious complications requiring immediate reoperations can occur, as can minor problems that will subject the patient to daily and nightly distress. Intestinal stomas undoubtedly will dramatically change lifestyles; patients will experience physiologic and psychologic detriment with stoma-related problems, however minor they may seem. Common complications include poor stoma siting, high output, skin irritation, ischemia, retraction, parastomal hernia (PH), and prolapse. Surgeons should be cognizant of these complications before, during, and after stoma creation, and adequate measures should be taken to avoid them. In this review, the authors highlight these often seen problems and discuss management and prevention strategies.

Fat embolism syndrome (FES) is an ill-defined clinical entity that arises from the systemic manifestations of fat emboli within the microcirculation. Embolized fat within capillary beds cause direct tissue damage as well as induce a systemic inflammatory response resulting in pulmonary, cutaneous, neurological, and retinal symptoms. This is most commonly seen following orthopedic trauma; however, patients with many clinical conditions including bone marrow transplant, pancreatitis, and following liposuction. No definitive diagnostic criteria or tests have been developed, making the diagnosis of FES difficult. While treatment for FES is largely supportive, early operative fixation of long bone fractures decreases the likelihood of a patient developing FES.

295 Background: Liver toxicity limits radiation therapy for liver metastasis; however, robotic radiosurgery delivers effective doses with limited toxicities. Robotic radiosurgery may be an effective treatment for liver metastases in patients with lesions not amenable to surgical resection. Methods: We conducted a retrospective study of patients treated with robotic radiosurgery for liver metastasis at our institution from June 2008 and June 2010. Medical records were reviewed and all cases discussed in multi-disciplinary conference. Preradiosurgery and follow-up abdominal computed tomography (CT) scans reviewed for treatment response. Our primary endpoint was local recurrence, defined as increased enhancement or tumor progression within the treatment field on follow-up CT scan. Results: Thirty-three patients had 37 liver metastasis treated with robotic radiosurgery (17 colorectal, 4 ovarian, 4 breast, 3 melanoma, 2 liver, 2 lung, 1 gastric, 1 cholangiocarcinoma, 1 pancreas, 1 anal, 1 bladder). Eighteen of 33 patients (54.5%) had isolated liver metastasis. Prior to radiosurgery 27 of 33 patients (81.8%) had undergone surgical resection of primary tumor, 26 of 33 patients (78.8%) were treated with chemotherapy for metastatic disease, and 15 of 33 patients (45.5%) had non-liver radiation therapy. Median time from primary diagnosis to radiosurgery treatment was 33.3 months (5.7 to 320 months). Patients received median radiation dose of 30 Gy (22.5 to 42) over 3 to 5 fractions. Median follow up was 8.1 months (1.2 to 23.5). There were no cases of liver failure. Sixteen patients had disease progression outside the treatment field (15 liver, 6 systemic) with a median time to progression of 4.6 months (0.9 to 17.6). Five lesions (13.5%) had in field progression with a median time to progression of 10 months (2.6 to 13.1). Seventeen patients (51.5%) died during follow-up. Conclusions: Robotic radiosurgery offers a potential local therapy for patients with metastatic liver disease with limited toxicity. Longer follow-up and more patients are required to better assess its safety. Robotic radiosurgery may fill a role for patients with lesions not amenable to traditional ablative and surgical techniques.