Alessandro Fichera M.D.

Sensi, B., Khan, J., Warusavitarne, J., Nardi, A., Spinelli, A., Zaghiyan, K., Panis, Y., Sampietro, G., Fichera, A., Garcia-Granero, E., Espin-Basany, E., Konishi, T., Siragusa, L., Stefan, S., Bellato, V., Carvello, M., Adams, E., Frontali, A., Artigue, M., Frasson, M., Marti-Gallostra, M., Pellino, G. and Sica, G.S. (2021). “Long-term oncological outcome of segmental versus extended colectomy for colorectal cancer in Crohn’s disease: results from an international multicentre study.” J Crohns Colitis Dec 13;jjab215. [Epub ahead of print].

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BACKGROUND AND AIMS: Crohn’s Disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn’s Disease recommend pan-proctocolectomy. Aim of this study was to evaluate oncologic outcomes of a less invasive surgical approach. METHODS: Retrospective database analysis of Crohn’s disease patients with colorectal cancer undergoing surgery at selected European and U.S. tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy: total colectomy and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer and major postoperative complications. RESULTS: Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older (p= 0.0429), had less extensive colitis (p = 0.0002) and no pre-operatively identified synchronous lesions (p = 0.0109).Median follow up was 43 (31-62) months. There was no difference in unadjusted progression-free survival (p = 0.2570) nor in overall survival (p = 0.4191) between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score and AJCC staging, confirmed no difference for progression-free survival (HR 1.00 p = 0.9993) or overall survival (HR 0.77 p = 0.6654). Synchronous and metachronous cancers incidence was 9% and 1.5% respectively. Perioperative mortality was nil and major complications were comparable (7.58% vs 6.06% p = 0.9998). CONCLUSIONS: Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results.

Campbell, S., Fichera, A., Thomas, S., Papaconstantinou, H. and Essani, R. (2022). “Outpatient colectomy-a dream or reality?” Proc (Bayl Univ Med Cent) 35(1): 24-27.

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Whereas the advancement of minimally invasive surgical techniques and enhanced recovery after surgery (ERAS) pathways for partial colectomies has shortened postoperative length of stay, the ideal length of stay after partial colectomy with or without diverting loop ileostomy is still up for debate. This article examines the safety and efficacy of discharging select patients home from day surgery following partial colectomy. We performed a retrospective review of 7 patients who underwent partial colectomy at one tertiary care center from December 2020 to August 2021. None of our cases suffered complications such as anastomotic leak, surgical site infection, or bowel obstruction or required admission to the hospital. One patient was seen in the emergency department on postoperative day 1 for nausea and vomiting and was managed as an outpatient. A second patient required a fluid bolus in the clinic for high ileostomy output. In conclusion, our study suggests that appropriately selected patients can be successfully managed in the outpatient setting without increased complications following partial colectomy when preoperative preparation and education are put in place alongside our colon ERAS pathway and minimally invasive surgical techniques.

https://bhslibrary-primo.hosted.exlibrisgroup.com/primo-explore/openurl?sid=Entrez:PubMed&id=pmid:34856589&vid=01TEXAM-HSC_V1&institution=01TEXAM-HSC&url_ctx_val=&url_ctx_fmt=null&isSerivcesPage=true

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BACKGROUND: Surgical site infections are a major preventable source of morbidity, mortality, and increased healthcare expenditure following colorectal surgery. Patients with penicillin allergy may not receive the recommended preoperative antibiotics, putting them at increased risk for surgical site infections. OBJECTIVE: This study aimed to evaluate the impact of patient-reported penicillin allergy on preoperative antibiotic prophylaxis and surgical site infection rates among patients undergoing major colon and rectal procedures. DESIGN: Retrospective observational study. SETTING: Tertiary teaching hospital in Dallas. PATIENTS: Adults undergoing colectomy or proctectomy between July 2012 to July 2019. MAIN OUTCOME MEASURES: Preoperative antibiotic choice and surgical site infection. RESULTS: Among 2198 patients included in the study, 12.26% (n=307) reported a penicillin allergy. Patients with penicillin allergy were more likely to be white (82%) and female (54%) (p<0.01). The most common type of allergic reaction reported was rash (36.5%), whereas 7.2% of patients reported anaphylaxis. Patients with self-reported penicillin allergy were less likely to receive beta-lactam antibiotics compared to patients who did not report a penicillin allergy (79.8% vs 96.7%, p<0.001). Overall, there were 143 (6.5%) patients with surgical site infections. On multivariable logistic regression there was no difference in rates of surgical site infection between patients with penicillin allergy vs. those without penicillin allergy (adjusted odds ratio 1.14; 95% confidence interval, 0.71-1.82). LIMITATIONS: Retrospective study design. CONCLUSIONS: Self-reported penicillin allergy among colorectal surgery patients is common, however only a small number of these patients report any serious adverse reactions. Patients with self-reported penicillin allergy are less likely to receive beta-lactam antibiotics and more likely to receive non beta-lactam antibiotics. However, this does not affect the rate of surgical site infection among these patients and patient's penicillin allergy can be safely prescribed non beta-lactam antibiotics without negatively impacting surgical site infection rates.

Dapri, G., N. A. Bascombe, S. O. Cawich and A. Fichera (2021). “Laparoscopic Right Hemicolectomy by Suprapubic Single-Incision With Different Intracorporeal Anastomoses.” Dis Colon Rectum Aug 18. [Epub ahead of print].

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In this video a laparoscopic right hemicolectomy, performed by suprapubic singleincision access is reported in a 45 years old female presenting an adenocarcinoma of the
caecum, classified as T2N0M0 at preoperative work-up. The different steps of the
procedure are showed in the video.

Bertucci Zoccali, M. and A. Fichera (2021). “Anastomotic Techniques for Abdominal Crohn’s Disease: Tricks and Tips.” J Laparoendosc Adv Surg Tech A 31(8): 861-866.

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After surgical resection for Crohn’s disease (CD) endoscopic recurrence is noted within few weeks and almost 80% of patients will have evidence of endoscopic recurrence at the anastomosis after ileocolic resection at 1 year. With time and if left untreated surgical recurrence will be detected at the preanastomotic segment or at the anastomosis in the vast majority of cases. It has become progressively apparent also based on these historical data that anastomotic configuration plays a major role in the subsequent recurrence of CD in surgically induced remission. In this article, we will review the evidence in the literature to support the different anastomotic configurations and we will discuss the principles of surgical prophylaxis of CD recurrence.