Alessandro Fichera M.D.

Sankaranarayanan, G., Parker, L., De, S., Kapadia, M. and Fichera, A. (2021). “Simulation for Colorectal Surgery.” J Laparoendosc Adv Surg Tech A 31(5): 566-569.

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Introduction: Colorectal surgery is a highly specialized field in surgery that deals with the surgical intervention of disease processes of the colon, rectum, and anus. Gaining proficiency in this field requires training both inside and outside of the operating room. Simulation plays a key role in training surgeons in colorectal surgery. The goal of this study is to review the currently available simulators for training in the field of colorectal surgery. Methods: A review of the literature was conducted to identify simulators that are both physical such as benchtop, live animal, and cadaver, as wells as virtual reality (VR) simulators. Any reported validity evidence for these simulators were also presented. Results: There are several benchtop physical models made of silicone for training in basic colorectal tasks, such as hand-sewn and stapled anastomosis. To improve realism, explanted animal and cadaveric specimens were also used for training. To improve repeatability, objective assessment, both commercial and VR simulators also exist for training in both open and laparoscopic colorectal surgery and emerging areas such as endoscopic submucosal dissection. Conclusion: Simulation-based training in colorectal surgery is here to stay and is going to play a significant role in training, credentialing, and quality improvements.

Lumpkin, S.T., Harvey, E., Mihas, P., Carey, T., Fichera, A. and Stitzenberg, K. (2021). “Understanding Patients’ Decisions to Obtain Unplanned, High-Resource Health Care After Colorectal Surgery.” Qual Health Res: 10497323211002479.

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Readmissions and emergency department (ED) visits after colorectal surgery (CRS) are common, burdensome, and costly. Effective strategies to reduce these unplanned postdischarge health care visits require a nuanced understanding of how and why patients make the decision to seek care. We used a purposefully stratified sample of 18 interview participants from a prospective cohort of adult CRS patients. Thirteen (72%) participants had an unplanned postdischarge health care visit. Participant decision-making was classified by methodology (algorithmic, guided, or impulsive), preexisting rationale, and emotional response to perceived health care needs. Participants voiced clear mental algorithms about when to visit an ED. In addition, participants identified facilitators and barriers to optimal health care use. They also identified tangible targets for health care utilization reduction efforts, such as improved care coordination with streamlined discharge instructions and improved communication with the surgical team. Efforts should be directed at improving postdischarge communication and care coordination to reduce CRS patients’ high-resource health care utilization.

Ferrari, L. and Fichera, A. (2021). “Clostridioides Difficile Infection.” Dis Colon Rectum 64(2): 151-155.

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A 70-year-old smoker with history of chronic obstructive pulmonary disease was admitted with a diagnosis of community-acquired pneumonia. She was started on macrolide antibiotic, and after 6 days she developed diarrhea (5 episodes over the previous 24 hours). Her stool sample was positive for Clostridioides difficile by nucleic acid amplification test and toxin-enzyme immunoassay using a 2-step algorithm. Her antibiotics were switched to vancomycin. Despite that she developed abdominal pain, distension, and respiratory distress 2 days later.
Surgical consultation was requested to rule out toxic megacolon or colonic perforation. An abdomen-pelvis CT scan was performed, which showed severe colonic dilatation and edematous haustral folds (Fig. 1). The patient underwent an urgent subtotal colectomy with end ileostomy. Intraoperatively she was found to have fecal peritonitis with perforation at the splenic flexure. Eventually she recovered uneventfully and was discharged 7 days after the operation. [No abstract; excerpt from article].

Dougherty, U., Mustafi, R., Zhu, H., Zhu, X., Deb, D., Meredith, S.C., Ayaloglu-Butun, F., Fletcher, M., Sanchez, A., Pekow, J., Deng, Z., Amini, N., Konda, V.J., Rao, V.L., Sakuraba, A., Kwesi, A., Kupfer, S.S., Fichera, A., Joseph, L., Hart, J., He, F., He, T.C., West-Szymanski, D., Li, Y.C. and Bissonnette, M. (2020). “Upregulation of polycistronic microRNA-143 and microRNA-145 in colonocytes suppresses colitis and inflammation-associated colon cancer.” Epigenetics Dec 28;1-18. [Epub ahead of print].

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Because ADAM17 promotes colonic tumorigenesis, we investigated potential miRNAs regulating ADAM17; and examined effects of diet and tumorigenesis on these miRNAs. We also examined pre-miRNA processing and tumour suppressor roles of several of these miRNAs in experimental colon cancer. Using TargetScan, miR-145, miR-148a, and miR-152 were predicted to regulate ADAM17. miR-143 was also investigated as miR-143 and miR-145 are co-transcribed and associated with decreased tumour growth. HCT116 colon cancer cells (CCC) were co-transfected with predicted ADAM17-regulating miRNAs and luciferase reporters controlled by ADAM17-3’UTR. Separately, pre-miR-143 processing by colonic cells was measured. miRNAs were quantified by RT-PCR. Tumours were induced with AOM/DSS in WT and transgenic mice (Tg) expressing pre-miR-143/miR-145 under villin promoter. HCT116 transfection with miR-145, -148a or -152, but not scrambled miRNA inhibited ADAM17 expression and luciferase activity. The latter was suppressed by mutations in ADAM17-3’UTR. Lysates from colonocytes, but not CCC, processed pre-miR-143 and mixing experiments suggested CCC lacked a competency factor. Colonic miR-143, miR-145, miR-148a, and miR-152 were downregulated in tumours and more moderately by feeding mice a Western diet. Tg mice were resistant to DSS colitis and had significantly lower cancer incidence and tumour multiplicity. Tg expression blocked up-regulation of putative targets of miR-143 and miR-145, including ADAM17, K-Ras, XPO5, and SET. miR-145, miR-148a, and miR-152 directly suppress colonocyte ADAM17 and are down-regulated in colon cancer. This is the first direct demonstration of tumour suppressor roles for miR-143 and miR-145 in an in vivo model of colonic tumorigenesis.

Kono, T. and Fichera, A. (2020). “Surgical Treatment for Crohn’s Disease: A Role of Kono-S Anastomosis in the West.” Clin Colon Rectal Surg 33(6): 335-343.

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More than 80% of patients with Crohn’s disease (CD) will require surgical intervention during their lifetime, with high rates of anastomotic recurrence and stenosis necessitating repeat surgery. Current data show that pharmacotherapy has not significantly improved the natural history of postoperative clinical and surgical recurrence of CD. In 2003, antimesenteric hand-sewn functional end-to-end (Kono-S) anastomosis was first performed in Japan. This technique has yielded very desirable outcomes in terms of reducing the incidence of anastomotic surgical recurrence. The most recent follow-up of these patients showed that very few had developed surgical recurrence. This new approach is superior to stapled functional end-to-end anastomosis because the stumps are sutured together to create a stabilizing structure (a “supporting column”), serving as a supportive backbone of the anastomosis to help prevent distortion of the anastomotic lumen due to disease recurrence and subsequent clinical symptoms. This technique requires careful mesenteric excision for optimal preservation of the blood supply and innervation. It also results in a very wide anastomotic lumen on the antimesenteric side. The Kono-S technique has shown efficacy in preventing surgical recurrence and the potential to become the new standard of care for intestinal CD.