Research Spotlight

Stringfield, S. B., G. O. Ogola, R. Curran, K. O. Wells, A. Fichera and J. W. Fleshman (2021). “Colorectal Surgery in COVID-Negative Patients in the Early Phases of the Pandemic: Short-Term Outcomes.” J Gastrointest Surg Aug 17;1-4. [Epub ahead of print]. 1-4.

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Many elective operations were canceled early in the COVID-19 pandemic in order to conserve resources and to keep patients out of public settings. Our institution canceled elective cases except those that were considered “medically necessary to correct a serious medical condition or to preserve the life of a patient 1.” For colorectal patients, this included emergencies and selected cases such as cancer resections. We noticed that a high number of patients that underwent surgery during this time developed postoperative ileus (POI) and had a prolonged hospital stay. Our hypothesis was that patients undergoing surgery during the pandemic had worse short-term outcomes, despite being COVID-negative. [No abstract; excerpt from article].

Jafari, M. D., A. Pigazzi, E. C. McLemore, M. G. Mutch, E. Haas, S. H. Rasheid, A. D. Wait, I. M. Paquette, O. Bardakcioglu, B. Safar, R. G. Landmann, M. G. Varma, D. J. Maron, J. Martz, J. J. Bauer, V. V. George, J. W. Fleshman, Jr., S. R. Steele and M. J. Stamos (2021). “Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes With PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.” Dis Colon Rectum 64(8): 995-1002.

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BACKGROUND: Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials. OBJECTIVE: We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection. DESIGN: We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years. SETTINGS: This was a multicenter trial. PATIENTS: Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge. INTERVENTION: Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy. MAIN OUTCOME MEASURES: Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention. RESULTS: This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34). LIMITATIONS: The predetermined sample size to adequately reduce the risk of type II error was not achieved. CONCLUSIONS: Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit.

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.

Fenves, A. Z. and M. Emmett (2021). “Approach to Patients With High Anion Gap Metabolic Acidosis: Core Curriculum 2021.” Am J Kidney Dis Aug 13;S0272-6386(21)00623-5. [Epub ahead of print].

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The anion gap (AG) is a mathematical construct that compares the blood sodium concentration with the sum of the chloride and bicarbonate concentrations. It is a helpful calculation that divides the metabolic acidoses into 2 categories: high AG metabolic acidosis (HAGMA) and hyperchloremic metabolic acidosis-and thereby delimits the potential etiologies of the disorder. When the [AG] is compared with changes in the bicarbonate concentration, other occult acid-base disorders can be identified. Furthermore, finding that the AG is very small or negative can suggest several occult clinical disorders or raise the possibility of electrolyte measurement artifacts. In this installment of AJKD’s Core Curriculum in Nephrology, we discuss cases that represent several very common and several rare causes of HAGMA. These case scenarios highlight how the AG can provide vital clues that direct the clinician toward the correct diagnosis. We also show how to calculate and, if necessary, correct the AG for hypoalbuminemia and severe hyperglycemia. Plasma osmolality and osmolal gap calculations are described and when used together with the AG guide appropriate clinical decision making.