Non-invasive monitoring of renal transplant recipients: Urinary excretion of soluble adhesion molecules and of the complement-split product C4d

Background: The number of inducible adhesion molecules known to be involved in cell-mediated allograft rejection is still increasing. In addition, recent data describe complement activation during acute humoral allograft rejection. The aim of this study was to assess whether specific molecules from either pathway are excreted into urine and whether they can provide useful diagnostic tools for the monitoring of renal transplant recipients. Methods: Urinary concentrations of soluble adhesion molecules (sICAM-1, sVCAM-1) and of the complement degradation product C4d were determined by standardized ELISA technique in 75 recipients of renal allografts and 29 healthy controls. Patient samples were assigned to four categories according to clinical criteria: group 1: acute steroid-sensitive rejection (ASSR, n=14), group 2: acute steroid-resistant rejection (ASRR, n=12), group 3: chronic allograft dysfunction (CAD, n=20) and group 4: stable graft function (SGF, n=29). Results: All patients with rejection episodes (groups 1-3) had significantly higher values of urinary sC4d compared with healthy controls and patients with stable graft function (p<0.05). The urinary levels of sVCAM-1 were significantly higher in group 2 (ASRR) compared with all other groups (p<0.001). Uniformly low amounts of s-VCAM-1 and complement-split product C4d were excreted by healthy controls (group 0). In contrast, urinary sICAM-1 concentration in healthy controls was almost as high as in group 2 (ASRR) whereas patients with a stable functioning graft (group 4) excreted significantly less sICAM-1 (p<0.05). Conclusion: The evaluation of sVCAM-1 and sC4d excretion in urine can provide a valuable tool with regard to the severity and type of allograft rejection. With respect to long-term allograft survival, serial measurements of these markers should have the potential to detect rejection episodes and prompt immediate treatment. Copyright (C) 2003 S. Karger AG, Basel

Robotic proctectomy for rectal cancer: analysis of 71 patients from a single institution

BackgroundDespite increasing use of robotic surgery for rectal cancer, few series have been published from the practice of generalizable US surgeons.MethodsA retrospective chart review was performed for 71 consecutive patients who underwent robotic low anterior resection (LAR) or abdominoperineal resection (APR) for rectal adenocarcinoma between 2010 and 2014.Results46 LARs (65%) and 25 APRs (35%) were identified. Median procedure time was 219 minutes (IQR 184–275) and mean blood loss 164.9 cc (SD 155.9 cc). Radial margin was negative in 70/71 (99%) patients. Total mesorectal excision integrity was complete/near complete in 38/39 (97%) of graded specimens. A mean of 16.8 (SD+/− 8.9) lymph nodes were retrieved. At median follow‐up of 21.9 months, there were no local recurrences.ConclusionsRobotic proctectomy for rectal cancer was introduced into typical colorectal surgery practice by a single surgeon, with a low conversion rate, low complication rate, and satisfactory oncologic outcomes.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/139933/1/rcs1841_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139933/2/rcs1841.pd

Non-invasive monitoring of renal transplant recipients: Urinary excretion of soluble adhesion molecules and of the complement-split product C4d

Background: The number of inducible adhesion molecules known to be involved in cell-mediated allograft rejection is still increasing. In addition, recent data describe complement activation during acute humoral allograft rejection. The aim of this study was to assess whether specific molecules from either pathway are excreted into urine and whether they can provide useful diagnostic tools for the monitoring of renal transplant recipients. Methods: Urinary concentrations of soluble adhesion molecules (sICAM-1, sVCAM-1) and of the complement degradation product C4d were determined by standardized ELISA technique in 75 recipients of renal allografts and 29 healthy controls. Patient samples were assigned to four categories according to clinical criteria: group 1: acute steroid-sensitive rejection (ASSR, n=14), group 2: acute steroid-resistant rejection (ASRR, n=12), group 3: chronic allograft dysfunction (CAD, n=20) and group 4: stable graft function (SGF, n=29). Results: All patients with rejection episodes (groups 1-3) had significantly higher values of urinary sC4d compared with healthy controls and patients with stable graft function (p<0.05). The urinary levels of sVCAM-1 were significantly higher in group 2 (ASRR) compared with all other groups (p<0.001). Uniformly low amounts of s-VCAM-1 and complement-split product C4d were excreted by healthy controls (group 0). In contrast, urinary sICAM-1 concentration in healthy controls was almost as high as in group 2 (ASRR) whereas patients with a stable functioning graft (group 4) excreted significantly less sICAM-1 (p<0.05). Conclusion: The evaluation of sVCAM-1 and sC4d excretion in urine can provide a valuable tool with regard to the severity and type of allograft rejection. With respect to long-term allograft survival, serial measurements of these markers should have the potential to detect rejection episodes and prompt immediate treatment. Copyright (C) 2003 S. Karger AG, Basel

Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium

PURPOSE: Anastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes. METHODS: This is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did or did not receive DLI during LAR. Secondary outcomes included risk factors for AL, receipt of adjuvant therapy, 3-year overall survival, and 3-year recurrence. RESULTS: Of 815 patients, 38 (4.7%) suffered AL after LAR. Patients with AL were more likely to be male, have unintentional preoperative weight loss, and are less likely to undergo DLI. On multivariable analysis, DLI remained protective against AL (p \u3c 0.001). Diverted patients were less likely to undergo future surgical procedures including additional ostomy creation, completion proctectomy, or pelvic washout for AL. Subgroup analysis of 456 patients with locally advanced disease showed that DLI was correlated with increased receipt of adjuvant therapy for patients with and without AL on univariate analysis (SHR:1.59; [95% CI 1.19-2.14]; p = 0.002), but significance was not met in multivariate models. CONCLUSION: Lack of DLI and preoperative weight loss was associated with anastomotic leak. Fecal diversion may improve the timely initiation of adjuvant oncologic therapy. The long-term outcomes following routine diverting stomas warrant further study

How Low Can We Go?: Comparing Long-term Oncologic Outcomes for APR and LAR in Very Low Rectal Cancer

Management of very low rectal cancer is one of the most challenging issues faced by colorectal surgeons. For tumors in the mid and upper rectum, procedures can be done to resect the cancer while maintaining continence, a major determinant of post-operative quality of life. In the low rectum, however, to optimize oncologic outcomes, many surgeons feel compelled to pursue abdominoperineal (APR) over low anterior resection (LAR), a sphincter-preserving procedure. It was hypothesized that after robust adjustment, procedure choice will not be associated with a difference in disease-free survival in the resection of tumors in the low rectum. To analyze this, the US Rectal Cancer Collaborative Database, a comprehensive, multi-center dataset obtained from six institutions between 2010 and 2016, was queried. Patients undergoing TME resection for Stage I-III very low rectal cancers (involvement) were selected for this study. Patients were categorized by procedure- LAR vs APR. Primary outcome was five-year disease-free survival. Secondary outcomes included overall survival, recurrence, length of stay, and complications. An adjusted analysis was performed to account for all known potential confounders. 431 patients with very low rectal cancer treated by either APR or LAR were identified. 154 (35.7%) underwent APR. The overall recurrence rate was 19.6%. Median follow-up time was 42.5 months. An analysis adjusted for age, gender, BMI, ASA class, and pathologic stage observed no difference in disease free survival between operative types (HR=0.90, 95% CI [0.53-1.52], p=0.70). Similarly, secondary outcomes demonstrated no significant difference between operation types, including length of stay (Beta: 0.04, Std. error = 0.25, p = 0.54), overall survival (HR=1.29, 95% CI [0.71-2.32], p=0.39), or complications (OR = 1.53, 95% CI [0.94 - 2.50], p=0.09). In this analysis, no significant difference in disease-free survival or overall survival was observed between patients undergoing APR or LAR for very low rectal cancer. This comprehensive study supports the treatment of very low rectal cancer, less than 5cm from the anorectal ring with no sphincter involvement, by either abdominal perineal or low anterior resection. Further studies may focus on patient-reported and quality of life outcomes which may influence decision-making

Cervical spondylosis with spinal cord encroachment: should preventive surgery be recommended?

<p>Abstract</p> <p>Background</p> <p>It has been stated that individuals who have spondylotic encroachment on the cervical spinal cord without myelopathy are at increased risk of spinal cord injury if they experience minor trauma. Preventive decompression surgery has been recommended for these individuals. The purpose of this paper is to provide the non-surgical spine specialist with information upon which to base advice to patients. The evidence behind claims of increased risk is investigated as well as the evidence regarding the risk of decompression surgery.</p> <p>Methods</p> <p>A literature search was conducted on the risk of spinal cord injury in individuals with asymptomatic cord encroachment and the risk and benefit of preventive decompression surgery.</p> <p>Results</p> <p>Three studies on the risk of spinal cord injury in this population met the inclusion criteria. All reported increased risk. However, none were prospective cohort studies or case-control studies, so the designs did not allow firm conclusions to be drawn. A number of studies and reviews of the risks and benefits of decompression surgery in patients with cervical myelopathy were found, but no studies were found that addressed surgery in asymptomatic individuals thought to be at risk. The complications of decompression surgery range from transient hoarseness to spinal cord injury, with rates ranging from 0.3% to 60%.</p> <p>Conclusion</p> <p>There is insufficient evidence that individuals with spondylotic spinal cord encroachment are at increased risk of spinal cord injury from minor trauma. Prospective cohort or case-control studies are needed to assess this risk. There is no evidence that prophylactic decompression surgery is helpful in this patient population. Decompression surgery appears to be helpful in patients with cervical myelopathy, but the significant risks may outweigh the unknown benefit in asymptomatic individuals. Thus, broad recommendations for decompression surgery in suspected at-risk individuals cannot be made. Recommendations to individual patients must consider possible unique circumstances.</p

Contemporary results from the PelvEx collaborative: improvements in surgical outcomes for locally advanced and recurrent rectal cancer

Aim: The PelvEx Collaborative collates global data on outcomes following exenterative surgery for locally advanced and locally recurrent rectal cancer (LARC and LRRC, respectively). The aim of this study is to report contemporary data from within the collaborative and benchmark it against previous PelvEx publications. Method: Anonymized data from 45 units that performed pelvic exenteration for LARC or LRRC between 2017 and 2021 were reviewed. The primary endpoints were surgical outcomes, including resection margin status, radicality of surgery, rates of reconstruction and associated morbidity and/or mortality. Results: Of 2186 patients who underwent an exenteration for either LARC or LRRC, 1386 (63.4%) had LARC and 800 (36.6%) had LRRC. The proportion of males to females was 1232:954. Median age was 62 years (interquartile range 52-71 years) compared with a median age of 63 in both historical LARC and LRRC cohorts. Compared with the original reported PelvEx data (2004-2014), there has been an increase in negative margin (R0) rates from 79.8% to 84.8% and from 55.4% to 71.7% in the LARC and LRRC cohorts, respectively. Bone resection and flap reconstruction rates have increased accordingly in both cohorts (8.2%-19.6% and 22.6%-32% for LARC and 20.3%-41.9% and 17.4%-32.1% in LRRC, respectively). Despite this, major morbidity has not increased. Conclusion: In the modern era, patients undergoing pelvic exenteration for advanced rectal cancer are undergoing more radical surgery and are more likely to achieve a negative resection margin (R0) with no increase in major morbidity