No features of intestinal obstruction or perforation CT chest, abdomen, and pelvis: Highly suspic... more No features of intestinal obstruction or perforation CT chest, abdomen, and pelvis: Highly suspicious wall thickening involving the distal transverse colon/splenic flexure with extramural involvement of the left colic and inferior mesenteric vein. Regional lymph nodes are enlarged. There is an associated collection measuring approximately 4.8 × 4.1 cm which is suggestive of focal tumor perforation. There is surrounding inflammatory changes and it is difficult to exclude associated peritoneal involvement. Such collection is abutting the gastric wall with edematous wall thickening and a likely perforation into the gastric lumen. No definite distant metastatic disease. Past medical history: Seven years before, patient had right breast invasive cancer. She underwent mastectomy with implant-based reconstruction, axillary clearance, chemoradiation therapy, and adjuvant endocrine treatment with Letrozole (aromatase inhibitor). Hospital course: The patient underwent upper endoscopy which showed a lesion within the stomach, biopsy showing inflammatory tissue and a colonoscopy which showed a transverse colon lesion consistent with invasive adenocarcinoma. The patient was then discharged awaiting colorectal multidisciplinary team discussion and readmitted 2 days later for nausea and inability to tolerate oral intake. An extended right hemicolectomy and en-block partial gastrectomy was recommended and performed as a combined procedure involving an upper and lower gastrointestinal surgeons. The anastomosis was protected with a diverting loop ileostomy. Key message: Patients with cancer involvement of multiple organs should be management in the context of a multidisciplinary team to optimize outcome. Small Bowel Obstruction Small bowel obstruction (SBO) is a common condition responsible for over 300,000 annual hospital admissions in the United States [1], associated with 10% of mortality rate and significant morbidities among survivors [2]. Small bowel obstruction occurs when the flow of contents through the intestines is interrupted. Simple SBO may lead to intestinal dilation, hypersecretion, bacterial overgrowth, and vascular impairment. Closed loop obstruction may immediately compromise mesenteric blood supply leading to ischemia, necrosis, and perforation with subsequent peritonitis. Patients with SBO are often unable to tolerate oral intake for several days and they should be considered as patients having acute intestinal failure, which has been defined by the European Society of Coloproctology as "the reduction of function below the minimum necessary for the absorption of macronutrients and/or fluids and electrolytes, such that intravenous supplementation is required to maintain health and/ or growth" [3].
The management of locally advanced rectal cancer has been a topic of debate between surgical scho... more The management of locally advanced rectal cancer has been a topic of debate between surgical schools in the East and the West, and to date, there is still no formal consensus or mutually agreed-on guidelines. While in Western countries, neoadjuvant chemoradiation therapy followed by total mesorectal excision has been the standard of care for 2 decades now, 2 recent studies 1,2 have demonstrated that this approach does not prevent lateral lymph node recurrence. 3 On the contrary, prophylactic lateral lymph node dissection has been the standard of care for locally advanced rectal cancer in Eastern countries, with predominance in Japan. 4 Pelvic magnetic resonance imaging (MRI) has become an invaluable instrument to establish local disease extension and lymph node involvement in locally advanced rectal cancer, with important prognostic value when it is repeated after the completion of neoadjuvant chemoradiation therapy to assess tumor response. 5 The study by Ogura et al 6 in this issue of JAMA Surgery addresses the difficulty in selecting patients who may benefit from lateral lymph node dissection in addition to neoadjuvant chemoradiation therapy and total mesorectal excision. 6 When we assess lateral lymph node involvement, size and localization are important both at the initial MRI as well as the post-neoadjuvant chemoradiation therapy MRI.
Postoperative Crohn’s disease recurrence can be defined as histologic, endoscopic, radiographic, ... more Postoperative Crohn’s disease recurrence can be defined as histologic, endoscopic, radiographic, clinical, or surgical. Recurrence rates may also vary according to the methodology of the individual study, for example randomized controlled trial versus observational and referral center experience versus a population-based cohort. Clinical and endoscopic recurrence rates are the most commonly reported postoperative Crohn’s disease measures. Clinical recurrence is defined by symptoms, such as diarrhea, weight loss, and abdominal pain. A variety symptom scores have been adapted to postoperative Crohn’s disease and include, the Inflammatory Bowel Disease Questionnaire or the Crohn’s disease activity index or Harvey-Bradshaw Index. The subjective nature of these symptom-based scores lends to a large variability of clinical recurrence rates across studies. Endoscopic recurrence that is defined at or above the ileocolonic anastomosis by ileocolonoscopy is a more objective measure. Endoscopic recurrence, defined by the Rutgeerts score, predicts subsequent clinical and surgical recurrence.5 The Rutgeerts score defines ileal lesions within 10 cm of the ileocolonic anastomosis as follows: i0: no lesions; i1: ≤5 apthous lesions; i2: >5 apthous lesions with normal mucosa between lesions, or skip areas of larger lesions, or lesions confined to the ileocolonic anastomosis <1 cm in length; i3: diffuse apthous ileitis with diffusely inflamed mucosa, and; i4: diffuse inflammation with already larger ulcers, nodules, or narrowing. At 3 years of follow-up, i0 and i1, i2, i3, and i4 scores are associated with 90 % likelihood of clinical recurrence, respectively.5 A recent comprehensive review looked at the incidence of endoscopic and clinical recurrence.6 These authors reported overall 5-year endoscopic recurrence rates of 89 and 58 % in patients from referral centers and population-based cohorts, respectively, and 5-year clinical recurrence rates of 41 and 30 %, respectively. Surgical recurrence generally follows clinical recurrence, and the surgical recurrence rates in population-based studies have decreased over time according to a recent review.7 Investigations conducted after 1980 demonstrated a 10-year surgical recurrence rate of 33 % [95 % confidence interval (CI): 31–35 %] compared to earlier studies that reported a rate of 45 % (95 % CI: 38–53 %). The enhancement of medication efficacy, employment of prophylactic medical therapy, and initiation of endoscopy-stimulated treatment likely influenced this reduction. The strongest predictors of postoperative recurrence are active cigarette smoking,6,8 penetrating disease behavior, and recurrent resectional surgery for Crohn’s disease. Other risk factors include perianal disease, extensive (>50 cm) small bowel disease, and early onset, aggressive disease.6
An association between hospital surgical volume and short- and long-term outcomes after pancreati... more An association between hospital surgical volume and short- and long-term outcomes after pancreatic surgery has been demonstrated. Identification of specific factors contributing to this relationship is difficult. In this study, the authors evaluated if margin status can be identified as a measure of surgical quality, affecting overall survival, as a function of hospital pancreaticoduodenectomy volume. A systematic review of the literature was performed. Two models for analysis were created, dividing the 18 studies identified into quartiles and two quantiles based on the average annual hospital pancreatectomy volume. Regression modeling and analysis of variance were used to find an association between hospital volume, margin status, and survival. Increasing hospital volume was associated with a significantly increased negative margin status rate: 55 per cent for low-volume, 72 per cent for medium-volume, 74.3 per cent for high-volume, and 75.7 per cent for very high-volume centers (P = 0.008). The negative margin status rates were 64 per cent and 75.1 per cent for volume centers with less and more than 12 pancreaticoduodenectomies/year, respectively (P = 0.04). Low-volume centers negatively affected both margin positive resection and 5-year survival rates, compared with high-volume centers. Margin status rate after pancreaticoduodenectomy could, therefore, be considered a measure of quality for selection of hospitals dedicated to pancreatic surgery.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, Jan 22, 2015
Fistulae-in-ano represent one of the more challenging anorectal diseases faced by surgeons, as ap... more Fistulae-in-ano represent one of the more challenging anorectal diseases faced by surgeons, as appropriate management requires careful balance between the need for local sepsis control and patients' desire to maintain fecal continence. The ligation of intersphincteric fistula tract (LIFT) procedure, first described by Rojanasakul and colleagues in 2007, represents a sphincter-sparing technique for fistula management which has become our method of choice for transsphincteric fistulas. With this technique, patients frequently enjoy successful fistula healing., or, at worst, conversion to a less complex fistula tract. Here, we describe and illustrate our surgical approach and review success and recurrence rates presented in the published literature.
The management of rectal cancer has evolved significantly in the last few decades. Significant im... more The management of rectal cancer has evolved significantly in the last few decades. Significant improvements in local disease control were achieved in the 1990s, with the introduction of total mesorectal excision and neoadjuvant radiotherapy. Level 1 evidence has shown that, with neoadjuvant chemoradiation therapy (CRT) the rates of local recurrence can be lower than 6% and, as a result, neoadjuvant CRT currently represents the accepted standard of care. This approach has led to reliable tumor down-staging, with 15-27% patients with a pathological complete response (pCR)-defined as no residual cancer found on histological examination of the specimen. Patients who achieve pCR after CRT have better long-term outcomes, less risk of developing local or distal recurrence and improved survival. For all these reasons, sphincter-preserving procedures or organ-preserving options have been suggested, such as local excision of residual tumor or the omission of surgery altogether. Although local recurrence rate has been stable at 5-6% with this multidisciplinary management method, distal recurrence rates for locally-advanced rectal cancers remain in excess of 25% and represent the main cause of death in these patients. For this reason, more recent trials have been looking at the administration of full-dose systemic chemotherapy in the neoadjuvant setting (in order to offer early treatment of disseminated micrometastases, thus improving control of systemic disease) and selective use of radiotherapy only in non-responders or for low rectal tumors smaller than 5 cm.
No features of intestinal obstruction or perforation CT chest, abdomen, and pelvis: Highly suspic... more No features of intestinal obstruction or perforation CT chest, abdomen, and pelvis: Highly suspicious wall thickening involving the distal transverse colon/splenic flexure with extramural involvement of the left colic and inferior mesenteric vein. Regional lymph nodes are enlarged. There is an associated collection measuring approximately 4.8 × 4.1 cm which is suggestive of focal tumor perforation. There is surrounding inflammatory changes and it is difficult to exclude associated peritoneal involvement. Such collection is abutting the gastric wall with edematous wall thickening and a likely perforation into the gastric lumen. No definite distant metastatic disease. Past medical history: Seven years before, patient had right breast invasive cancer. She underwent mastectomy with implant-based reconstruction, axillary clearance, chemoradiation therapy, and adjuvant endocrine treatment with Letrozole (aromatase inhibitor). Hospital course: The patient underwent upper endoscopy which showed a lesion within the stomach, biopsy showing inflammatory tissue and a colonoscopy which showed a transverse colon lesion consistent with invasive adenocarcinoma. The patient was then discharged awaiting colorectal multidisciplinary team discussion and readmitted 2 days later for nausea and inability to tolerate oral intake. An extended right hemicolectomy and en-block partial gastrectomy was recommended and performed as a combined procedure involving an upper and lower gastrointestinal surgeons. The anastomosis was protected with a diverting loop ileostomy. Key message: Patients with cancer involvement of multiple organs should be management in the context of a multidisciplinary team to optimize outcome. Small Bowel Obstruction Small bowel obstruction (SBO) is a common condition responsible for over 300,000 annual hospital admissions in the United States [1], associated with 10% of mortality rate and significant morbidities among survivors [2]. Small bowel obstruction occurs when the flow of contents through the intestines is interrupted. Simple SBO may lead to intestinal dilation, hypersecretion, bacterial overgrowth, and vascular impairment. Closed loop obstruction may immediately compromise mesenteric blood supply leading to ischemia, necrosis, and perforation with subsequent peritonitis. Patients with SBO are often unable to tolerate oral intake for several days and they should be considered as patients having acute intestinal failure, which has been defined by the European Society of Coloproctology as "the reduction of function below the minimum necessary for the absorption of macronutrients and/or fluids and electrolytes, such that intravenous supplementation is required to maintain health and/ or growth" [3].
The management of locally advanced rectal cancer has been a topic of debate between surgical scho... more The management of locally advanced rectal cancer has been a topic of debate between surgical schools in the East and the West, and to date, there is still no formal consensus or mutually agreed-on guidelines. While in Western countries, neoadjuvant chemoradiation therapy followed by total mesorectal excision has been the standard of care for 2 decades now, 2 recent studies 1,2 have demonstrated that this approach does not prevent lateral lymph node recurrence. 3 On the contrary, prophylactic lateral lymph node dissection has been the standard of care for locally advanced rectal cancer in Eastern countries, with predominance in Japan. 4 Pelvic magnetic resonance imaging (MRI) has become an invaluable instrument to establish local disease extension and lymph node involvement in locally advanced rectal cancer, with important prognostic value when it is repeated after the completion of neoadjuvant chemoradiation therapy to assess tumor response. 5 The study by Ogura et al 6 in this issue of JAMA Surgery addresses the difficulty in selecting patients who may benefit from lateral lymph node dissection in addition to neoadjuvant chemoradiation therapy and total mesorectal excision. 6 When we assess lateral lymph node involvement, size and localization are important both at the initial MRI as well as the post-neoadjuvant chemoradiation therapy MRI.
Postoperative Crohn’s disease recurrence can be defined as histologic, endoscopic, radiographic, ... more Postoperative Crohn’s disease recurrence can be defined as histologic, endoscopic, radiographic, clinical, or surgical. Recurrence rates may also vary according to the methodology of the individual study, for example randomized controlled trial versus observational and referral center experience versus a population-based cohort. Clinical and endoscopic recurrence rates are the most commonly reported postoperative Crohn’s disease measures. Clinical recurrence is defined by symptoms, such as diarrhea, weight loss, and abdominal pain. A variety symptom scores have been adapted to postoperative Crohn’s disease and include, the Inflammatory Bowel Disease Questionnaire or the Crohn’s disease activity index or Harvey-Bradshaw Index. The subjective nature of these symptom-based scores lends to a large variability of clinical recurrence rates across studies. Endoscopic recurrence that is defined at or above the ileocolonic anastomosis by ileocolonoscopy is a more objective measure. Endoscopic recurrence, defined by the Rutgeerts score, predicts subsequent clinical and surgical recurrence.5 The Rutgeerts score defines ileal lesions within 10 cm of the ileocolonic anastomosis as follows: i0: no lesions; i1: ≤5 apthous lesions; i2: >5 apthous lesions with normal mucosa between lesions, or skip areas of larger lesions, or lesions confined to the ileocolonic anastomosis <1 cm in length; i3: diffuse apthous ileitis with diffusely inflamed mucosa, and; i4: diffuse inflammation with already larger ulcers, nodules, or narrowing. At 3 years of follow-up, i0 and i1, i2, i3, and i4 scores are associated with 90 % likelihood of clinical recurrence, respectively.5 A recent comprehensive review looked at the incidence of endoscopic and clinical recurrence.6 These authors reported overall 5-year endoscopic recurrence rates of 89 and 58 % in patients from referral centers and population-based cohorts, respectively, and 5-year clinical recurrence rates of 41 and 30 %, respectively. Surgical recurrence generally follows clinical recurrence, and the surgical recurrence rates in population-based studies have decreased over time according to a recent review.7 Investigations conducted after 1980 demonstrated a 10-year surgical recurrence rate of 33 % [95 % confidence interval (CI): 31–35 %] compared to earlier studies that reported a rate of 45 % (95 % CI: 38–53 %). The enhancement of medication efficacy, employment of prophylactic medical therapy, and initiation of endoscopy-stimulated treatment likely influenced this reduction. The strongest predictors of postoperative recurrence are active cigarette smoking,6,8 penetrating disease behavior, and recurrent resectional surgery for Crohn’s disease. Other risk factors include perianal disease, extensive (>50 cm) small bowel disease, and early onset, aggressive disease.6
An association between hospital surgical volume and short- and long-term outcomes after pancreati... more An association between hospital surgical volume and short- and long-term outcomes after pancreatic surgery has been demonstrated. Identification of specific factors contributing to this relationship is difficult. In this study, the authors evaluated if margin status can be identified as a measure of surgical quality, affecting overall survival, as a function of hospital pancreaticoduodenectomy volume. A systematic review of the literature was performed. Two models for analysis were created, dividing the 18 studies identified into quartiles and two quantiles based on the average annual hospital pancreatectomy volume. Regression modeling and analysis of variance were used to find an association between hospital volume, margin status, and survival. Increasing hospital volume was associated with a significantly increased negative margin status rate: 55 per cent for low-volume, 72 per cent for medium-volume, 74.3 per cent for high-volume, and 75.7 per cent for very high-volume centers (P = 0.008). The negative margin status rates were 64 per cent and 75.1 per cent for volume centers with less and more than 12 pancreaticoduodenectomies/year, respectively (P = 0.04). Low-volume centers negatively affected both margin positive resection and 5-year survival rates, compared with high-volume centers. Margin status rate after pancreaticoduodenectomy could, therefore, be considered a measure of quality for selection of hospitals dedicated to pancreatic surgery.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, Jan 22, 2015
Fistulae-in-ano represent one of the more challenging anorectal diseases faced by surgeons, as ap... more Fistulae-in-ano represent one of the more challenging anorectal diseases faced by surgeons, as appropriate management requires careful balance between the need for local sepsis control and patients' desire to maintain fecal continence. The ligation of intersphincteric fistula tract (LIFT) procedure, first described by Rojanasakul and colleagues in 2007, represents a sphincter-sparing technique for fistula management which has become our method of choice for transsphincteric fistulas. With this technique, patients frequently enjoy successful fistula healing., or, at worst, conversion to a less complex fistula tract. Here, we describe and illustrate our surgical approach and review success and recurrence rates presented in the published literature.
The management of rectal cancer has evolved significantly in the last few decades. Significant im... more The management of rectal cancer has evolved significantly in the last few decades. Significant improvements in local disease control were achieved in the 1990s, with the introduction of total mesorectal excision and neoadjuvant radiotherapy. Level 1 evidence has shown that, with neoadjuvant chemoradiation therapy (CRT) the rates of local recurrence can be lower than 6% and, as a result, neoadjuvant CRT currently represents the accepted standard of care. This approach has led to reliable tumor down-staging, with 15-27% patients with a pathological complete response (pCR)-defined as no residual cancer found on histological examination of the specimen. Patients who achieve pCR after CRT have better long-term outcomes, less risk of developing local or distal recurrence and improved survival. For all these reasons, sphincter-preserving procedures or organ-preserving options have been suggested, such as local excision of residual tumor or the omission of surgery altogether. Although local recurrence rate has been stable at 5-6% with this multidisciplinary management method, distal recurrence rates for locally-advanced rectal cancers remain in excess of 25% and represent the main cause of death in these patients. For this reason, more recent trials have been looking at the administration of full-dose systemic chemotherapy in the neoadjuvant setting (in order to offer early treatment of disseminated micrometastases, thus improving control of systemic disease) and selective use of radiotherapy only in non-responders or for low rectal tumors smaller than 5 cm.
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Papers by Linda Ferrari