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Background and Objectives: The goal of this study was to compare disease-specific risk factors and 30-day outcomes between patients with Crohn's disease (CD) and colon cancer (CC) undergoing right-sided surgical resection. Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP®) was interrogated to extract all patients ≥18 years undergoing elective right-sided resection for CD versus CC. Independent risk factors for surgical complications were identified through multivariable logistic regression for both groups. In a second step, surgical and medical 30-day morbidity was compared after risk adjustment. Results: The cohort consisted of 17,516 patients, of which 2,899 (16.6%) underwent surgery for CD versus 14,617 (83.4%) for CC. Independent risk factors for surgical complications in patients with CD were male gender, African American race, ASA score (III or IV), active smoking, prolonged surgery, and preoperative anemia. Independent risk factors for surgical complications in the cancer group were age ≥70 years, male gender, ASA score (III or IV), respiratory and cardiovascular comorbidities, and preoperative hypoalbuminemia (<3.5 g/dL). After risk adjustment, surgical complications (OR 1.25, p = 0.002), sepsis (OR 1.64, p = 0.012), and unplanned readmissions (OR 1.39, p = 0.004) were more common in patients with CD. Thirty-day mortality was higher in cancer patients (1.1 vs. 0.1%, p < 0.0001). Conclusions: Patients with Crohn's disease were more prone to surgical complications and postoperative sepsis compared to the cancer group undergoing the same procedure. Careful evaluation and correction of disease-specific modifiable risk factors of patients with CD and CC, respectively, are important. [ABSTRACT FROM AUTHOR]

Background: BMI ≤18.5 kg/m2 and preoperative weight loss may lead to inaccurate assessment of nutritional status, given the increasing prevalence of obesity. The aim of this study was to assess whether clinical evaluation of malnutrition based on these parameters is sufficient to predict complications after colorectal cancer surgery. Materials and Methods: The American College of Surgeons-National Quality Improvement Program database was queried from 2005 to 2018. Patients undergoing elective colorectal cancer surgery were divided into 4 groups: (1) albumin <3.1 g/dL within 21 days of surgery, (2) European Society for Clinical Nutrition and Metabolism (ESPEN) 2 clinical parameters for malnutrition (≥10% loss of weight/6 months plus [BMI <20 kg/m2 if age <70 years OR BMI <22 kg/m2 if age ≥70 years]), (3) both aforementioned criteria, and (4) none of aforementioned criteria. Results: Of 82,280 patients, 5,932 (7.2%) had hypoalbuminemia <3.1 g/dL, 764 (0.9%) fulfilled clinical ESPEN 2 parameters, and 338 (0.4%) met both criteria. After adjusting for baseline confounders, patients in the hypoalbuminemia group had a higher risk of overall complications (odds ratio [OR] 1.92, p < 0.05 vs. OR 1.18 in the ESPEN 2 group, p < 0.05), major complications (OR 1.98, p < 0.05 vs. OR 1.20, p < 0.05), surgical complications (OR 1.77, 95% p < 0.05 vs. OR 1.1, p > 0.05), medical complications (OR 1.73, p < 0.05 vs. OR 1.16, p > 0.05), surgical site infection (OR 1.32, p < 0.05 vs. OR 0.86, p > 0.05), and prolonged hospitalization (OR 1.79, p < 0.05 vs. OR 1.22, p < 0.05). Patients who met both criteria were at highest risk. Conclusions: Preoperative measurement of serum albumin appears to be essential to identify patients at risk for complications after colorectal cancer surgery. Clinical evaluation through BMI and weight loss alone may underestimate surgery-associated risks in the USA. [ABSTRACT FROM AUTHOR]

The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice. [ABSTRACT FROM AUTHOR]

Background Despite extensive efforts to monitor and prevent surgical site infections (SSIs), real-time surveillance of clinical practice has been sparse and expensive or nonexistent. However, natural language processing (NLP) and machine learning (i.e., Bayesian network analysis) may provide the methodology necessary to approach this issue in a new way. We investigated the ability to identify SSIs after colorectal surgery (CRS) through an automated detection system using a Bayesian network. Materials and methods Patients who underwent CRS from 2010 to 2012 and were captured in our institutional American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) comprised our cohort. A Bayesian network was applied to detect SSIs using risk factors from ACS-NSQIP data and keywords extracted from clinical notes by NLP. Two surgeons provided expertise informing the Bayesian network to identify clinically meaningful SSIs (CM-SSIs) occurring within 30 d after surgery. Results We used data from 751 CRS cases experiencing 67 (8.9%) SSIs and 78 (10.4%) CM-SSIs. Our Bayesian network detected ACS-NSQIP-captured SSIs with a receiver operating characteristic area under the curve of 0.827, but this value increased to 0.892 when using surgeon-identified CM-SSIs. Conclusions A Bayesian network coupled with NLP has the potential to be used in real-time SSI surveillance. Moreover, surgeons identified CM-SSI not captured under current NSQIP definitions. Future efforts to expand CM-SSI identification may lead to improved and potentially automated approaches to survey for postoperative SSI in clinical practice. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to evaluate clinico-pathologic specific predictors of recurrence for stage II/III disease. Improving recurrence prediction for resected stage II/III colon cancer patients could alter surveillance strategies, providing opportunities for more informed use of chemotherapy for high risk individuals. Methods 871 stage II and 265 stage III patients with colon cancers were included. Features studied included surgery date, age, gender, chemotherapy, tumor location, number of positive lymph nodes, tumor differentiation, and lymphovascular and perineural invasion. Time to recurrence was evaluated, using Cox's proportional hazards models. The predictive ability of the multivariable models was evaluated using the concordance (c) index. Results For stage II cancer patients, estimated recurrence-free survival rates at one, three, five, and seven years following surgery were 98%, 92%, 90%, and 89%. Only T stage was significantly associated with recurrence. Estimated recurrence-free survival rates for stage III patients at one, three, five, and seven years following surgery were 94%, 78%, 70%, and 66%. Higher recurrence rates were seen in patients who didn't receive chemotherapy (p = 0.023), with a higher number of positive nodes (p < 0.001). The c-index for the stage II model was 0.55 and 0.68 for stage III. Conclusions Current clinic-pathologic information is inadequate for prediction of colon cancer recurrence after resection for stage II and IIII patients. Identification and clinical use of molecular markers to identify the earlier stage II and III colon cancer patients at elevated risk of recurrence are needed to improve prognostication of early stage colon cancers. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate clinico-pathologic specific predictors of recurrence for stage II/III disease. Improving recurrence prediction for resected stage II/III colon cancer patients could alter surveillance strategies, providing opportunities for more informed use of chemotherapy for high risk individuals. Methods: 871 stage II and 265 stage III patients with colon cancers were included. Features studied included surgery date, age, gender, chemotherapy, tumor location, number of positive lymph nodes, tumor differentiation, and lymphovascular and perineural invasion. Time to recurrence was evaluated, using Cox's proportional hazards models. The predictive ability of the multivariable models was evaluated using the concordance (c) index. Results: For stage II cancer patients, estimated recurrence-free survival rates at one, three, five, and seven years following surgery were 98%, 92%, 90%, and 89%. Only T stage was significantly associated with recurrence. Estimated recurrence-free survival rates for stage III patients at one, three, five, and seven years following surgery were 94%, 78%, 70%, and 66%. Higher recurrence rates were seen in patients who didn't receive chemotherapy (p = 0.023), with a higher number of positive nodes (p < 0.001). The c-index for the stage II model was 0.55 and 0.68 for stage III. Conclusions: Current clinic-pathologic information is inadequate for prediction of colon cancer recurrence after resection for stage II and IIII patients. Identification and clinical use of molecular markers to identify the earlier stage II and III colon cancer patients at elevated risk of recurrence are needed to improve prognostication of early stage colon cancers. [ABSTRACT FROM AUTHOR]

Background: Fast-track (FT) postoperative protocols have been shown to be highly beneficial in open colectomy. Some have questioned the necessity of an FT protocol in the setting of laparoscopic colectomy because hospital stays are short and morbidity is low compared with open surgery. We set out to determine whether an FT protocol has any utility in the setting of elective laparoscopic colectomy. Study Design: A retrospective review was conducted on a cohort of 334 patients who underwent elective laparoscopic sigmoid resection for diverticulitis from 1998 to 2008, at Mayo Clinic, a tertiary care center in Rochester, MN. There were 235 patients who were managed with traditional postoperative care, and 99 who were managed with an FT protocol initiated in 2006. The main outcomes measures were time to soft diet, length of stay, overall morbidity, and readmission rate. Results: Times to soft diet (mean 2.3 vs 3.6 days), and first bowel movement (mean 2.6 vs 3.5 days) were shorter in the FT group (p < 0.001). The median lengths of stay were 3 days (interquartile range 3 to 4 days) and 5 days (interquartile range 4 to 6 days) for the FT and non-FT groups, respectively (p < 0.001). Morbidity was significantly lower in the FT group compared with the non-FT group (15.2% vs 25.5%, p < 0.03). The 30-day readmission rate was 2.9% for the FT group and 7.6% for the non-FT group (p = NS). There were no deaths in either group. Conclusions: Even in patients undergoing laparoscopic colectomy, FT protocols further improve the speed of gastrointestinal recovery, shorten the length of stay, and decrease morbidity. [ABSTRACT FROM AUTHOR]

Introduction: Meckel's diverticulum is a common congenital anomaly of the gastrointestinal tract, but is an uncommon cause of serious complications in adults. Although cases of patients with hemorrhage, bowel obstruction or perforation associated with Meckel's diverticulum have been reported, there have been no prior reports of patients with combined urinary and bowel obstruction due to abscess formation.Case Presentation: We describe the case of a 21-year-old man with a history of recurrent papillary thyroid cancer, but no prior abdominal surgeries, who presented with a one-month history of rectal pain and new-onset obstipation with urinary retention. He reported night sweats and weight loss, and had a second-degree relative with known Crohn's disease. A digital rectal examination was notable and revealed marked tenderness with proximal induration. A computed tomography scan of the patient's abdomen revealed a large, complex, circumferential perirectal abscess compressing the rectal lumen and base of the urinary bladder, associated with terminal ileal thickening and an ileocecal fistula. A flexible sigmoidoscopy with an endorectal ultrasound scan displayed a complex abscess with extensive mucosal and surrounding inflammation. An exploratory laparotomy revealed a Meckel's diverticulum with a large perforation at its base, positioned near the ileocecal fistula and immediately superior to the perirectal abscess. The section of small bowel containing the Meckel's diverticulum, the terminal ileum, and the cecum, were all resected, and the abscess was debrided.Conclusions: Pre-operative diagnosis of Meckel's diverticulum can be difficult. If the nature of the complication makes ultimate surgical management likely, an early laparoscopic or open exploration should be performed to prevent the morbidity and mortality associated with late complications. [ABSTRACT FROM AUTHOR]

Outcomes of laparoscopic resection for ileocecal Crohn’s disease have been reported previously in smaller studies, suggesting its short-term advantages over open surgery. This study assessed the safety and recovery parameters in the largest, consecutive, single-institution series to date. Consecutive patients undergoing laparoscopically assisted primary ileocolic resection for Crohn’s disease between 1994 and 2006 were identified in an institutional prospectively collected database. Operative and postoperative outcomes at 30 days were studied. In this study, 109 patients (35 men) with a mean age of 35 ± 14 years and a mean body mass index (BMI) of 25 ± 6 kg/m2 were identified. The main indications for surgery were medically refractory disease (63%) and fibrous stenosis (27%). In 41% of the cases, previous abdominal surgery had been performed. The surgery had a mean duration of 150 ± 45 min and a conversion rate of 6%. The overall 30-day morbidity rate was 11%, and the reoperation rate was 1%. The mortality rate was 0%. The median postoperative hospital stay was 4 days (range, 2–15 days). This series, the largest reported to date, concurs with recent metaanalyses findings that laparoscopically assisted primary ileocecal resection for Crohn’s disease is safe and feasible, resulting in better short-terms outcomes than open resection. This operation is therefore the procedure of choice for Crohn’s disease at our institutions. [ABSTRACT FROM AUTHOR]

Background: The use of defunctioning stomas has been advocated to mitigate the adverse sequela from anastomotic dehiscence after rectal cancer resection. The aim of this study was to report our experience with anastomotic dehiscence and overall morbidity of low anterior resections in the era of neoadjuvant therapy, where the use of fecal diversion is part of the standard operative strategy for low (< 5 cm) rectal anastomoses. Study Design: This retrospective case series included patients who were treated with neoadjuvant therapy and had rectal cancer resection with curative intent, from 1996 to 2007. Results: Two hundred thirty-seven patients (159 men, 78 women) with mean age of 59 years (SD±12.7 years), received 5-flurouracil–based infusional chemotherapy and external-beam radiation in the range of 45 to 54 Gy. Fifty-seven percent of patients underwent anterior resection and 43% had coloanal anastomosis. Anastomotic dehiscence occurred in 9 patients (3.8%). Seven of the anastomotic leaks were diagnosed as pelvic abscesses (2.1%) and 2 patients needed reexploration (0.8%). Early overall postoperative morbidity was 26%, and there was no postoperative mortality. One hundred ninety-one of 193 patients had their ileostomy reversed, with minimal morbidity (0.5% leak rate). Conclusions: Low postoperative morbidity after colorectal and coloanal anastomosis for adenocarcinoma is possible in patients who have received neoadjuvant therapy. Defunctioning stomas are safe and may mitigate the serious sequela of anastomotic dehiscence after low rectal anastomoses. [Copyright &y& Elsevier]

Laparoscopic surgery of the colon has become an established method for the resection of both benign and malignant disease. Complex laparoscopic colon resections were once stigmatized due to their longer operating times and inherent technical difficulty. However, technological innovations and increased surgical experience with laparoscopy have advanced the field of complex laparoscopic surgery, including ileal pouch-anal anastomosis (IPAA) procedure, with safe feasible results. When these operations are broken down in a stepwise fashion, the complexity of the laparoscopic IPAA procedure becomes simplified, allowing one to effectively reproduce this operation. The systematic laparoscopic steps outlined establish a simple, reproducible approach to a laparoscopic IPAA procedure for ulcerative colitis patients. This approach to laparoscopic IPAA provides one with a viable approach to this complex operation. [ABSTRACT FROM AUTHOR]

The operative management of rectal complications after radiation for prostate cancer has been incompletely studied. Our aim was to determine a logical surgical approach to these severe rectal complications. From an institutional database, we identified 5719 patients who were evaluated between 1990 and 2003 with a history of prostate cancer that was treated with radiation. Fourteen patients were identified from this group who underwent operative intervention for complications stemming from radiation. Charts were retrospectively reviewed for demographics, prostate cancer treatment, rectal symptoms, diagnostic techniques, operative interventions, and outcome. Ten patients (71%) had documented rectourethral fistulas. An additional four patients (29%) had either transfusion-dependent rectal bleeding or intractable fecal incontinence. Using a surgical algorithm, we proceeded with fecal diversion alone (20%), urinary and fecal diversion alone (50%), and primary repair with or without a tissue flap and fecal diversion (29%) in the 14 affected patients. Symptomatic improvement and resolution of these three complications occurred in 12 (85%) of patients. However, only 2 (15%) were able to retain their intestinal continuity to achieve this outcome. The introduction of a step-wise approach to this problem has resulted in symptomatic resolution in the majority of patients. However, this is achieved at the cost of permanent fecal and sometimes urinary diversion. [Copyright &y& Elsevier]

Laparoscopic segmental colectomy has been widely accepted as a surgical procedure for benign colonic disease. With improving technology and surgeon experience, more complex procedures have been performed. However, a minimal invasive approach may not be justified for all colonic diseases. The use of laparoscopic surgery for colonic cancer, for example, has been controversial and the results of our national and international trials are yet unknown. We anticipate, given the positive findings of multiple small randomized and nonrandomized trials, that laparoscopic colectomy for cancer may soon prove to be appropriate in this setting. Our aim in this paper is to explore the indications, contraindications, and techniques regarding laparoscopic surgery that we have used in the treatment of colon cancer for patients enrolled in the national trial. [Copyright &y& Elsevier]

The Maze procedure has been demonstrated to eliminate atrial fibrillation (AF) refractory to medical management. The procedure, however, is technically difficult and requires prolonged cardiopulmonary bypass (CPB). We investigated the use of epicardially applied radiofrequency (RF) energy delivered using a saline-irrigated probe to functionally reproduce the linear lesions of the surgical Maze procedure. The goals of this study were to safely produce transmural atrial insulation lines without CPB and to investigate whether they could retain their electrical insulation properties and structural integrity over an acute time period. Baseline pacing thresholds were measured on the atria of six swine. Then, circular insulating lesions (n = 11) were created around each pacing site using a saline-irrigated RF probe and specifically designed radiofrequency generator. Pacing thresholds were repeated at the same atrial sites, and in adjacent areas, immediately following lesion creation and at 7 days. At sacrifice the areas of interest were removed for histopathology. Pacing thresholds increased from 0.9 ± 0.09 V to 9.59 ± 0.87 V immediately following lesion formation (p < .05) and remained supraphysiologic at 4.05 ± 0.36 V after 7 days (p < .05). Thresholds from outside the lesions were unchanged from baseline. There was no evidence of perforation and histologic analysis demonstrated transmural necrosis with advancing granulation tissue. Our data suggest that epicardially applied RF energy coupled with saline irrigation can produce transmural electrical insulation lines for up to 7 days. However, the decreasing trend in thresholds toward baseline suggests further investigation is needed to verify insulation line continuity over a chronic time period. These lines were created safely and efficiently without CPB, and may be applicable to a minimally invasive Maze procedure. [ABSTRACT FROM AUTHOR]

BACKGROUND: The COVID-19 pandemic has severely affected healthcare systems globally, resulting in significant delays and challenges in various medical treatments, particularly in cancer care. This study aims to investigate the repercussions of the pandemic on surgical interventions for colorectal cancer (CRC) in the US, using data from the National Cancer Database. STUDY DESIGN: We conducted a retrospective analysis of the National Cancer Database, encompassing adult patients who underwent surgical procedures for colon and rectal cancer in 2019 (pre-COVID) and 2020 (COVID). We examined various demographic and clinical variables, including patient characteristics, tumor staging, surgical approaches, and socioeconomic factors. RESULTS: The analysis included 105,517 patients, revealing a 17.3% reduction in surgical cases during the initial year of the pandemic. Patients who underwent surgery in 2020 displayed more advanced clinical and pathological tumor stages compared to those treated in 2019. After diagnosis, no delay was reported in the treatment. Patients operated during the pandemic, Black patients, uninsured, and Medicaid beneficiaries had worse stage colon and rectal cancer, and individuals with lower incomes bore the burden of advanced colon cancer. CONCLUSIONS: The impact of the COVID-19 pandemic on CRC surgery transcends a mere decline in case numbers, resulting in a higher prevalence of patients with advanced disease. This study underscores the exacerbated disparities in cancer care, particularly affecting vulnerable populations. The COVID-19 pandemic has left a significant and enduring imprint on CRC surgery, intensifying the challenges faced by patients and healthcare systems. Comprehensive studies are imperative to comprehend the long-term consequences of delayed screenings, diagnoses, and treatments as healthcare planning for the future must consider the unintended repercussions of pandemic-related disruptions. [ABSTRACT FROM AUTHOR]

This article, published in the journal Colorectal Disease, presents a standardized approach to robot-assisted oncological sigmoid resection using the Da Vinci Xi® system. The video vignette demonstrates a seven-step procedure for this type of surgery, which aims to be reproducible and easy to teach. The steps include various dissections and ligations, as well as mobilization of the colon and rectum. The article also mentions the use of laparoscopic-assisted anastomosis in some cases. The authors of the article are Héloïse Giron, Amaniel Kefleyesus, David W. Larson, and Fabian Grass. [Extracted from the article]

Background: The introduction of laparoscopy in 1989 revolutionized surgical practices, reducing post-operative complications, and enhancing outcomes. Despite its benefits, limitations in laparoscopic tools have led to continued use of open surgery. Robotic-assisted surgery emerged to address these limitations, but its adoption trends and potential impact on open and laparoscopic surgery require analysis. Methods: A retrospective analysis used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases from 2012 to 2021. The study encompassed various abdominal procedures, employing Vector Autoregressive (VAR) models to analyze the dynamic relationships between surgical techniques. The models predicted future trends in open, laparoscopic, and robotic surgery until Q2 of 2025. Results: The analysis included 360,171 patients across diverse procedures. In urology, robotic surgery dominated prostatectomies (83.1% in 2021) and nephrectomies (55.1% in 2021), while the open approach remained the predominant surgical technique for cystectomies (72.5% in 2021). In general surgery, robotic colectomies were forecasted to surpass laparoscopy, becoming the primary approach by 2024 (45.7% in 2025). Proctectomies also showed a shift towards robotic surgery, predicted to surpass laparoscopy and open surgery by 2025 (32.3%). Pancreatectomies witnessed a steady growth in robotic surgery, surpassing laparoscopy in 2021, with forecasts indicating further increase. While hepatectomies remained predominantly open (70.0% in 2025), esophagectomies saw a rise in robotic surgery, predicted to become the primary approach by 2025 (52.3%). Conclusions: The study suggests a transformative shift towards robotic-assisted surgery, poised to dominate various minimally invasive procedures. The forecasts indicate that robotic surgery may surpass laparoscopy and open surgery in colectomies, proctectomies, pancreatectomies, and esophagectomies by 2025. This anticipated change emphasizes the need for proactive adjustments in surgical training programs to align with evolving surgical practices. The findings have substantial implications for future healthcare practices, necessitating a balance between traditional laparoscopy and the burgeoning role of robotic-assisted surgery. [ABSTRACT FROM AUTHOR]

Background: Up to 20% of patients with ileal pouch will develop pouch failure, ultimately requiring surgical reintervention. As a result of the complexity of reoperative pouch surgery, minimally invasive approaches were rarely utilized. In this series, we present the outcomes of the patients who underwent robotic-assisted pouch revision or excision to assess its feasibility and short-term results. Methods: All the patients affected by inflammatory bowel diseases and familial adenomatous polyposis who underwent robotic reoperative surgery of an existing ileal pouch were included. Results: Twenty-two patients were included; 54.6% were female. The average age at reoperation was 51 ± 16 years, with a mean body mass index of 26.1 ± 5.6 kg/m2. Fourteen (63.7%) had a diagnosis of ulcerative colitis at reoperation, and seven (31.8%) had Crohn's disease. The mean time to pouch reoperation was 12.8 ± 11.8 years. Seventeen (77.3%) patients underwent pouch excision, and five (22.7%) had pouch revision surgery. The mean operative time was 372 ± 131 min, and the estimated blood loss was 199 ± 196.7 ml. The conversion rate was 9.1%, the 30-day morbidity rate was 27.3% (with only one complication reaching Clavien–Dindo grade IIIB), and the mean length of stay was 5.8 ± 3.9 days. The readmission rate was 18.2%, the reoperation rate was 4.6%, and mortality was nihil. All patients in the pouch revisional group are stoma-free. Conclusion: Robotic reoperative pouch surgery in highly selected patients is technically feasible with acceptable outcomes. [ABSTRACT FROM AUTHOR]

Aim: Locally advanced rectal cancer (LARC) is commonly treated with neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME) to reduce local recurrence (LR) and improve survival. However, LR, particularly associated with lateral lymph node (LLN) involvement, remains a concern. The aim of this study was to investigate preoperative factors associated with LLN involvement and their impact on LR rates in LARC patients undergoing nCRT and curative surgery. Method: This multicentre retrospective study, including four academic high‐volume institutions, involved 301 consecutive adult LARC patients treated with nCRT and curative surgery between January 2014 and December 2019 who did not undergo lateral lymph node dissection (LLND). Baseline and restaging pelvic MRIs were evaluated for suspicious LLNs based on institutional criteria. Patients were divided into two groups: cLLN+ (positive nodes) and cLLN– (no suspicious nodes). Primary outcome measures were LR and lateral local recurrence (LLR) rates at 3 years. Results: Among the cohort, 15.9% had suspicious LLNs on baseline MRI, and 9.3% had abnormal LLNs on restaging MRI. At 3 years, LR and LLR rates were 4.0% and 1.0%, respectively. Ten out of 12 (83.3%) patients with LR showed no suspicious LLNs at the baseline MRI. Abnormal LLNs on MRI were not independent risk factors for LR, distant recurrence or disease‐free survival. Conclusion: Abnormal LLNs on baseline and restaging MRI assessment did not impact LR and LLR rates in this cohort of patients with LARC submitted to nCRT and curative TME surgery. [ABSTRACT FROM AUTHOR]

Background: Up to 20% of patients with ileal pouch will develop pouch failure, ultimately requiring surgical reintervention. As a result of the complexity of reoperative pouch surgery, minimally invasive approaches were rarely utilized. In this series, we present the outcomes of the patients who underwent robotic-assisted pouch revision or excision to assess its feasibility and short-term results. Methods: All the patients affected by inflammatory bowel diseases and familial adenomatous polyposis who underwent robotic reoperative surgery of an existing ileal pouch were included. Results: Twenty-two patients were included; 54.6% were female. The average age at reoperation was 51 ± 16 years, with a mean body mass index of 26.1 ± 5.6 kg/m2. Fourteen (63.7%) had a diagnosis of ulcerative colitis at reoperation, and seven (31.8%) had Crohn’s disease. The mean time to pouch reoperation was 12.8 ± 11.8 years. Seventeen (77.3%) patients underwent pouch excision, and five (22.7%) had pouch revision surgery. The mean operative time was 372 ± 131 min, and the estimated blood loss was 199 ± 196.7 ml. The conversion rate was 9.1%, the 30-day morbidity rate was 27.3% (with only one complication reaching Clavien–Dindo grade IIIB), and the mean length of stay was 5.8 ± 3.9 days. The readmission rate was 18.2%, the reoperation rate was 4.6%, and mortality was nihil. All patients in the pouch revisional group are stoma-free. Conclusion: Robotic reoperative pouch surgery in highly selected patients is technically feasible with acceptable outcomes. [ABSTRACT FROM AUTHOR]

Laparoscopy in colorectal surgery reduces the rate of postoperative complications, shortens the length of stay in hospital, and improves the quality of patient care. Despite these established benefits, the technical challenges of rectal resection for cancer have resulted in most operations being performed through open surgery in the USA. Moreover, controversy in the current literature questions the oncologic safety of a laparoscopic approach for rectal cancer. How then can surgeons innovate to overcome the technical challenges while preserving the critical oncological outcomes of high-quality rectal cancer surgery? Robotics may be a platform that allows us to overcome the technical challenges in the pelvis while maintaining both oncological outcomes and the benefits of a minimally invasive technique. Current evidence suggests that the quality of total mesorectal excision, the rates of circumferential margin involvement, and postoperative outcomes are comparable between robotic and laparoscopic surgery. While a robotic approach demonstrates lower conversion rates and reduced surgeon workload, the operative time is longer and initial costs are higher; however, time and future science will determine its true benefits. We review the current state of robotic surgery and its impact on rectal cancer surgery. [ABSTRACT FROM AUTHOR]

Open combined resections of colorectal primary tumors and synchronous liver metastases have become common in selected cases. However, evidences favoring a minimally invasive (MIS) approach are still limited. The aim of this study is to evaluate the outcomes of MIS vs. open synchronous liver and colorectal resections. 384 cases of synchronous colorectal and liver resections performed at one institution were identified during the study period. MIS vs open approach were compared after a propensity score matching; surgical outcomes were analyzed. MIS cases featured longer operative time (399 vs 300 min, p < 0.001), fewer blood loss (200 vs 500 ml, p = 0.003), and shorter hospitalization (median LOS 4 vs 6 days, p = 0.001). No difference was observed between the two groups for use of Pringle maneuver (p = 0.083), intraoperative blood transfusion (p = 0.061), achievement of negative colorectal (p = 0.176) and liver margins (p = 1.000), postoperative complications (p = 1.000) and significant (Clavien-Dindo ≥ 3a) complications (p = 0.817), delay of adjuvant therapy due to complications (p = 0.555), 30- and 90-day mortality. Synchronous colorectal and liver metastases resections via a minimally-invasive approach in high-volume centers with appropriate expertise result in significantly lower blood loss and length of stay despite longer operative time in comparison to open, with no oncological inferiority. [ABSTRACT FROM AUTHOR]

Few series have reported on the impact of robotic right colectomy compared with conventional laparoscopy. Even fewer have reported on the outcomes of intracorporeal anastomoses. The aim of our study was to determine the impact of robotic surgery on short-term operative outcomes in patients undergoing right colectomy with intracorporeal anastomosis. One hundred and fourteen consecutive patients who underwent a right colectomy by two colorectal surgeons between 2012 and 2017 were included. Patients were separated into two groups: laparoscopic technique with extracorporeal anastomosis (n = 87) and robotic technique with intracorporeal anastomosis (n = 27). Univariate analysis was performed to determine differences in outcomes. Differences between cohorts were only identified with regard to gender (62 vs 37%, P = 0.022) and year of surgery. In comparison with laparoscopy, robotic colectomy resulted in a shorter time of GI recovery (1.3 ± 0.6 vs 3 ± 1.1, P < 0.0001), lower rates of postoperative ileus (4 vs 28%, P = 0.007), lower overall morbidity (26 vs 52%, P = 0.019), less blood loss (P = 0.001), 50 per cent lower narcotic use, and longer operative time (255 ± 66 vs 139 ± 49, P < 0.001). Despite longer operative time, robotic surgery improved GI recovery, significantly lowered oral morphine equivalent usage, and decreased short-term complications. [ABSTRACT FROM AUTHOR]

Hospital-specific electronic health record systems are used to inform clinical practice about best practices and quality improvements. Many surgical centers have developed deterministic clinical decision rules to discover adverse events (e.g. postoperative complications) using electronic health record data. However, these data provide opportunities to use probabilistic methods for early prediction of adverse health events, which may be more informative than deterministic algorithms. Electronic health record data from a set of 9598 colorectal surgery cases from 2010 to 2014 were used to predict the occurrence of selected complications including surgical site infection, ileus, and bleeding. Consistent with previous studies, we find a high rate of missing values for both covariates and complication information (4-90%). Several machine learning classification methods are trained on an 80% random sample of cases and tested on a remaining holdout set. Predictive performance varies by complication, although an area under the receiver operating characteristic curve as high as 0.86 on testing data was achieved for bleeding complications, and accuracy for all complications compares favorably to existing clinical decision rules. Our results confirm that electronic health records provide opportunities for improved risk prediction of surgical complications; however, consideration of data quality and consistency standards is an important step in predictive modeling with such data. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate clinico-pathologic specific predictors of recurrence for stage II/III disease. Improving recurrence prediction for resected stage II/III colon cancer patients could alter surveillance strategies, providing opportunities for more informed use of chemotherapy for high risk individuals.Methods: 871 stage II and 265 stage III patients with colon cancers were included. Features studied included surgery date, age, gender, chemotherapy, tumor location, number of positive lymph nodes, tumor differentiation, and lymphovascular and perineural invasion. Time to recurrence was evaluated, using Cox's proportional hazards models. The predictive ability of the multivariable models was evaluated using the concordance (c) index.Results: For stage II cancer patients, estimated recurrence-free survival rates at one, three, five, and seven years following surgery were 98%, 92%, 90%, and 89%. Only T stage was significantly associated with recurrence. Estimated recurrence-free survival rates for stage III patients at one, three, five, and seven years following surgery were 94%, 78%, 70%, and 66%. Higher recurrence rates were seen in patients who didn't receive chemotherapy (p = 0.023), with a higher number of positive nodes (p < 0.001). The c-index for the stage II model was 0.55 and 0.68 for stage III.Conclusions: Current clinic-pathologic information is inadequate for prediction of colon cancer recurrence after resection for stage II and IIII patients. Identification and clinical use of molecular markers to identify the earlier stage II and III colon cancer patients at elevated risk of recurrence are needed to improve prognostication of early stage colon cancers. [ABSTRACT FROM AUTHOR]

Purpose: One-third of patients with Crohn’s disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). Methods: This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center. Results: Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p = 0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p = 0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3 ± 2.5 vs. ECA-M: 4.1 ± 2.4 days; p = 0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p = 0.064] and readmission rates [7(11.9) vs. 18(9.5); p = 0.59]. Conclusion: Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk. [ABSTRACT FROM AUTHOR]

Aim: Surgical treatment of splenic flexure cancer (SFC) still presents some debated issues, including the role of laparoscopic surgery. The literature is based on small single‐centre series, while randomized controlled studies comparing open and laparoscopic treatment for colon cancer exclude SFC. This study aimed to determine the role of laparoscopic surgery in the treatment of SFC, comparing short‐ and long‐term outcomes with open surgery. Method: This was an international multicentre retrospective cohort study that analysed patients from 10 tertiary referral centres. From a cohort of 641 cases, 484 patients with Stage I–III SFC submitted to elective surgery with curative intent were selected. After 1:1 propensity score matching, 130 patients in the laparoscopic group (LapGroup) were compared with 130 patients in the open surgery group (OpenGroup). Results: After propensity score matching, the two groups were comparable for demographic and clinical parameters. OpenGroup presented a higher incidence of overall (P = 0.02) and surgery‐related complications (P = 0.05) but a similar rate of severe complications (P = 0.75). Length of stay was notably shorter in the LapGroup (P = 0.001). Overall (P = 0.793) as well as cancer‐specific survival (P = 0.63) did not differ between the two groups. Conclusions: Elective laparoscopic surgery for Stage I–III SFC is feasible and associated with improved short‐term postoperative outcomes compared to open surgery. Moreover, laparoscopic surgery appears to provide excellent long‐term cancer outcomes. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to identify national utilization trends of robotic surgery for elective colectomy, conversion rates over time, and the specific impact of conversion on postoperative morbidity. Conversion to open represents a hard endpoint for minimally invasive surgery (MIS) and is associated with worse outcomes when compared to MIS or even traditional open procedures. Methods: All adult patients who underwent either laparoscopic or robotic elective colectomy from 2013 to 2018 as reported in the American College of Surgeons Quality Improvement Program (ACS-NSQIP) database were included. National trends of both robotic utilization and conversion rates were analyzed, overall and according to underlying disease (benign disease, inflammatory bowel disease (IBD), cancer), or the presence of obesity (body mass index (BMI) ≥ 30 kg/m2). Demographic and surgical risk factors for surgical conversion to open were identified through multivariable regression analysis. Further assessed were overall and specific postoperative 30-day complications, which were risk adjusted and compared between converted patients and the remaining cohort. Results: Of 66,652 included procedures, 5353 (8.0%) were converted to open. Conversion rates were 8.5% for laparoscopic and 4.9% for robotic surgery (p < 0.0001). A decline in conversion rates over the 6-year inclusion period was observed overall and for patients with obesity. This trend paralleled an increased utilization of the robotic platform. Several surrogates for advanced disease stages for cancer, diverticulitis, and IBD and prolonged surgical duration were identified as independent risk factors for unplanned conversion, while robotic approach was an independent protective factor (OR 0.44, p < 0.0001). Patients who had unplanned conversion were more likely to experience postoperative complications (OR 2.36; 95% CI [2.21–2.51]), length of hospital stay ≥ 6 days (OR 2.86; 95% CI [2.67–3.05], and 30-day mortality (OR 2.28; 95% CI [1.72–3.02]). Conclusion: This nationwide study identified a decreasing trend in conversion rates over the 6-year inclusion period, both overall and in patients with obesity, paralleling increased utilization of the robotic platform. Unplanned conversion to open was associated with a higher risk of postoperative complications. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic-assisted colectomy (LAC) is not performed widely despite numerous patient benefits. LAC is difficult to perform and the learning curve is steep. Hand-assisted laparoscopy (HALS) permits placement of a hand into the abdomen to assist the dissection. Our aim was to analyze the impact of HALS on a minimal access colectomy (MAC) practice. Study Design: A prospectively maintained database was retrospectively reviewed for all LAC and HALS colectomies. HALS was introduced in November 2003, and analysis was performed for the ensuing 3-year period. Procedure types, conversion rates, operation duration, complications, and length of stay were determined. Results: During the study period, 969 MACs were performed (373 HALS, 596 LAC). Although HALS was used for all types of colorectal resection, it was most commonly used for complex colectomies (left-sided and total colectomies). HALS complex colectomies increased 44% from 2004 to 2005, and 24% from 2005 to 2006. Conversely, LAC complex colectomies decreased 29% (2004 to 2005) and then increased 27% (2005 to 2006). There were no demographic differences between patient groups. For complex colectomies, HALS substantially reduced operative time (mean ± SD; LAC, 258±90minutes; HALS, 242±89minutes; p=0.037) and conversion rate (LAC, 15.3% versus HALS, 3.4%, p < 0.001), with the same complication rate (LAC, 13.6%; HALS, 15.4%; p=0.629). The average length of stay (mean ± SD) was increased 1 day in the HALS group (LAC, 5.0±3.0 days; HALS, 6.0±3.4 days; p < 0.001), likely because of the higher proportion of total colectomies. Conclusions: HALS increased the number of MACs performed. More notably, HALS was used preferentially for complex colectomies. HALS effectively bridges the complexity divide between minimal access and open procedures. HALS may serve as a technology to expand MAC. [Copyright &y& Elsevier]

Background: The aim of this analysis was to determine the impact of complicated and uncomplicated diverticulitis on conversion rates and complications in patients undergoing laparoscopic surgery (LS) for diverticular disease.Methods: Between 1993 and 2004, 125 patients underwent LS [91 laparoscopic-assisted (LA) and 34 hand-assisted (HA) colectomy for diverticular disease, 79 uncomplicated and 46 complicated]. Cases not completed laparoscopically were considered converted. Complicated diverticulitis was defined as diverticular disease associated with abscess, fistula, bleeding or stricture.Results: The mean age was 59 years with 67 (54%) men with a mean follow-up of 23 months. The conversion rate was 26% (33 patients). The only factor independently associated with conversion was a history of previous abdominal surgery (37% vs. 14%, p = 0.004). Among the subset of patients undergoing surgery for uncomplicated diverticulitis, the number of diverticulitis episodes (DE), the time between the first and last DE, and the time between the last DE and surgery, were not significantly associated with conversion. Early complications (<30 days from surgery) occurred in 30 (25%) patients. Twenty-one long-term complications (>30 days from surgery) occurred in 20 patients and the one and two-year cumulative probabilities of these complications were 14% and 22%, respectively. Early complications were significantly higher among patients requiring conversion (44% vs. 24%, p = 0.04) but were not significantly higher among patients with complicated diverticulitis (39% vs. 24%, p = 0.11). The rates of long-term complications were not significantly higher among patients that required conversion or had complicated diverticulitis (one-year rate 23% vs. 11%, p = 0.47; 18% vs. 13%, p = 0.70).Conclusions: A previous history of abdominal surgery was associated with a higher conversion rate in patients undergoing laparoscopic surgery for diverticular disease. Long-term patient outcomes are not adversely impacted by laparoscopic surgery for complicated diverticulitis or laparoscopic surgery requiring conversion to an open procedure. [ABSTRACT FROM AUTHOR]

Background: Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the preferred operation for patients with chronic ulcerative colitis (CUC) refractory to medical therapy. Infliximab (IFX), an antitumor necrosis factor−α antibody, has demonstrated efficacy in medical management of CUC. The aim of this study is to determine if IFX before IPAA impacts short-term outcomes. Study Design: A prospective institutional database was retrospectively reviewed for short-term complications after IPAA for CUC. Postoperative outcomes were compared between patients who received pre-IPAA IFX and those who did not. Results: Between 2002 and 2005, 47 patients received IFX before IPAA, and 254 patients received none. There were no gender (p = 0.16) or body mass index (p = 0.07) differences between groups. IFX patients were younger than non-IFX patients (mean age 28.1 to 39.3 years) (p < 0.001). In IFX patients, 70% were receiving preoperative IFX, azathioprine, and corticosteroids. Mortality was nil. Overall surgical morbidity was similar: 61.7% and 48.8%, IFX and non-IFX, respectively (p = 0.10). Anastomotic leaks (p = 0.02), pouch-specific (p = 0.01) and infectious (p < 0.01) complications were more common in IFX patients. Multivariable analysis revealed IFX as the only factor independently associated with infectious complications (odds ratio [OR] = 3.5; CI, 1.6−7.5). In a separate analysis, incorporating age, high-dose corticosteroids, azathioprine, and severity of colitis, IFX remained significantly associated with infectious complications (OR = 2.7; CI, 1.1−6.7). Conclusions: CUC patients treated with IFX before IPAA have substantially increased the odds of postoperative pouch-related and infectious complications. Additional prospective studies are required to determine if IFX alone or other factors contribute to the observed increases in infectious complications. [Copyright &y& Elsevier]

Background: Obesity is a risk factor for failure of pouch surgery completion. However, little is known about the impact of obesity on short-term outcomes after minimally invasive (MIS) ileal pouch-anal anastomosis (IPAA). This study aimed to assess short-term postoperative outcomes in patients undergoing MIS total proctocolectomy (TPC) with IPAA in patients with and without obesity. Materials and methods: All adult patients (≥ 18 years old) who underwent MIS IPAA as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files 2007 to 2018 were included. Patients were divided according to their body mass index (BMI) into two groups (BMI ≥ 30 kg/m2 vs. BMI < 30 kg/m2). Baseline demographics, preoperative risk factors including comorbidities, American Society of Anesthesiologists Class, smoking, different preoperative laboratory parameters, and operation time were compared between the two groups. Propensity score matching (1:1) based on logistic regression with a caliber distance of 0.2 of the standard deviation of the logit of the propensity score was used to overcome biases due to different distributions of the covariates. Thirty-day postoperative complications including overall surgical and medical complications, surgical site infection (SSI), organ space infection, systemic sepsis, 30-day mortality, and length of stay were compared between both groups. Results: Initially, a total of 2158 patients (402 (18.6%) obese and 1756 (81.4%) nonobese patients) were identified. After 1:1 matching, 402 patients remained in each group. Patients with obesity had a higher risk of postoperative organ/space infection (12.9%; vs. 6.5%; p-value 0.002) compared to nonobese patients. There was no difference between the groups regarding the risk of postoperative sepsis, septic shock, need for blood transfusion, wound disruption, superficial SSI, deep SSI, respiratory, renal, major adverse cardiovascular events (myocardial infarction, stroke, cardiac arrest requiring cardiopulmonary resuscitation), venous thromboembolism, 30-day mortality, and length of stay. Conclusion: MIS IPAA can be safely performed in patients with obesity. However, patients with obesity have a 2-fold risk of organ space infection compared to patients without obesity. Loss of weight before MIS IPAA is recommended not only to allow for pouch creation but also to decrease organ space infections. [ABSTRACT FROM AUTHOR]

Rationale: The aim of this study was to identify temporal readmission patterns according to baseline disease categories to provide opportunities for targeted interventions. Methods: Retrospective analysis of consecutive adult (≥18 years) patients who underwent elective colorectal resections (2011‐2017) at Mayo Clinic Rochester, MN. A prospective administrative database including patient demographics, procedure characteristics, discharge information and specifics on 30‐day readmissions (to index facility) including timing and reasons was utilized. The ICD‐9 codes were regrouped into the main pathologies Cancer, Crohn's disease (CD)/chronic ulcerative colitis (CUC), and diverticular disease. Results: In total, 521 (7.2%) out of 7245 patients undergoing inpatient colorectal surgery were readmitted. In all increments of time from discharge (0‐2 days: 31.3% of all readmissions, 3‐7 days: 32.4% of all readmissions, 8‐14 days: 18% of all readmissions, and 15‐30 days: 18.3% of all readmissions), reasons for readmission differed significantly (all P < 0.001). Across all disease categories, early readmissions (within 2 days of discharge) were most likely due to ileus/obstruction (53.4% of early readmissions), whereas with 42.5%, infection was the most common cause for late readmissions (>7 days). Patients with home discharge were more likely to be readmitted earlier within the 30‐day observation period (P = 0.099), whereas patients with a longer length of index hospital stay (>7 days) were readmitted later (P = 0.080). Conclusions: Reasons for readmission appear to be universal across different disease categories. Targeted educational and collaborative measures may help to mitigate the burden of hospital readmissions to index facilities. [ABSTRACT FROM AUTHOR]

Background: The most common complications after colorectal surgery, postoperative ileus, surgical site infections, and anastomotic leaks continue to occur despite advances in surgical technique and enhanced recovery pathways. Preclinical studies have documented that intestinal bacteria play a role in the development of these complication, yet human data is lacking. Here we hypothesized that patients that develop ileus, surgical site infection, and/or anastomotic leak following colorectal surgery harbor a specific preoperative gut microbiome. Methods: We performed a prospective cohort study on 101 patients undergoing colon or rectal resection at the Mayo Clinic. Rectal samples were collected preoperatively and on the ward on postoperative day two. The bacterial community from each sample was characterized by 16S rRNA and associated with the development of complications. Results: The rectal microbiome collected from patients in the operating room (p =.003) and on postoperative day two (p =.001) was significantly difference in patients whom later developed postoperative ileus compared with patients that had a normal return of bowel function. Patients whom developed ileus showed increased abundance of Bacteroides spp., Parabacteroides spp., and Ruminococcus spp., bacteria that are associated with promoting intestinal inflammation. There were no differences in the microbiome in patients that developed surgical site infections or anastomotic leaks. Conclusions: In this pilot study, patients that develop postoperative ileus harbor a specific gut microbiome during the perioperative period. These findings demonstrate that the preoperative bacterial composition may predispose patients to the development of ileus and that perioperative manipulation of the gut bacteria may provide a novel method to promote normal return of bowel function. [ABSTRACT FROM AUTHOR]

This study aimed to assess intra- and postoperative outcomes of robotic resection of left-sided complicated diverticular disease. Retrospective analysis of a prospectively maintained institutional database on consecutive patients undergoing elective robotic resection for diverticular disease (2014-2018). All procedures were performed within an enhanced recovery pathway (ERP). Demographic, surgical and ERP-related items were compared between patients with simple and complicated diverticular disease according to intra-operative presentation. Postoperative complications and length of stay were compared between the two groups. Out of 150 patients, 78 (52%) presented with complicated and the remaining 72 (48%) with uncomplicated disease. Both groups were comparable regarding demographic baseline characteristics and overall ERP compliance. Surgery for complicated disease was longer (288 ± 96 vs. 258 ± 72 min, p = 0.04) and more contaminated (≥ class 3: 57.7 vs. 23.6%, p < 0.001) with a trend to higher conversion rates (10.3 vs. 2.8%, p = 0.1). While postoperative overall complications tended to occur more often after resections for complicated disease (28.2 vs. 15.3%, p = 0.075), major, surgical and medical complications did not differ between the two groups, and median length of stay was 3 days in both settings (p = 0.19). Robotic resection of diverticular disease was feasible and safe regardless of disease presentation by the time of surgery. [ABSTRACT FROM AUTHOR]

Objectives: To reduce the technical challenges of a totally minimally invasive approach (TMA) and to decrease the morbidity associated with open surgery, a hybrid minimally invasive/open approach (HMOA) has been introduced as a surgical technique for rectal cancer. The aim of this study was to compare postoperative results and long-term oncologic outcomes between hybrid minimally invasive/open approach and totally minimally invasive approach in patients who underwent rectal resection for cancer. Methods: All patients with rectal cancer undergoing a totally minimally invasive approach or hybrid minimally invasive/open approach proctectomy between 2012 and 2016 were analyzed. Preoperative and postoperative outcomes were collected from a prospectively maintained institutional database. Results: Among 283 patients, 138 (48.8%) underwent a hybrid minimally invasive/open approach and 145 (51.2%) a totally minimally invasive approach. Preoperative characteristics were similar between groups except for distance from the anal verge, which was lower in totally minimally invasive approach group (50.7% vs 29%; p = 0.0008). Length of stay (LOS) was significantly longer in the hybrid minimally invasive/open approach group (6.4 vs 4.3; p = < 0.0001). The median follow-up was 29.6 (14–40.6) months. Overall survival and disease-free survival were not significantly different between groups. Conclusions: Compared with a hybrid minimally invasive/open approach, a totally minimally invasive approach has a shorter length of stay and may improve short-term outcomes in patients undergoing proctectomy for cancer. [ABSTRACT FROM AUTHOR]

Abstract Background Little information exists to help colon and rectal surgery residency programs determine which factors applicants find important when selecting a training program. Our aim was to identify factors applicants find pertinent in the selection of their desired colon and rectal surgery residency program. Methods After the 2016 and 2017 National Resident Matching Program (The Match), a 58-question anonymous web-based survey was sent to all trainees who applied to our colon and rectal surgery residency program to determine factors applicants find important in selecting colon and rectal surgery residency training programs. Results Of 196 invitation emails sent, a total of five were returned with unidentifiable addresses leaving 191 surveys for possible completion. The survey response rate was 62.8% (n = 120). The top 10 areas identified as strongly to moderately influential in residency program selection included faculty experience, balanced training, operative volume, operative complexity, autonomy, faculty reputation, employment opportunities, Accreditation Council for Graduate Medical Education index case volumes, office/clinic complexity, and current resident/fellow input. Conclusions Multiple elements were identified as strongly to moderately influential when selecting a training program. Training programs can use these named factors for resident recruitment, development, and self-assessment. [ABSTRACT FROM AUTHOR]

Background: Few studies have examined opioid usage in the post-discharge period. The primary aim of this study was to evaluate the need for post-discharge opioids in a unique set of patients: those undergoing colorectal operations and experiencing no surgical complications. The secondary aim was to examine the accuracy of the Opioid Risk Tool (ORT) to predict the need for additional opioid prescriptions. Our hypotheses were that few patients would require post-discharge opioids and that the ORT would predict patients requiring post-discharge opioids.Methods: All patients undergoing elective colorectal surgery between January 2012 and December 2014 that did not experience NSQIP complications within 30 days or receive an opioid prescription in the 2 weeks prior to operation were reviewed. ORT score was calculated for all patients. Patients requiring post-discharge opioids within 1 year were compared to those not receiving additional opioids after discharge.Results: There were 367 patients that met inclusion criteria and 56 (15%) received post-discharge opioids. Opioid use in the year prior to surgery was the only significant risk factor to receive post-discharge opioids. Opioids were prescribed for three distinct reasons by three groups of prescribers. The ORT did not accurately predict need for post-discharge opioids.Conclusions: Even among patients without complications, 15% received post-discharge opioid prescriptions. Previous opioid use within the year prior to surgery was a major risk factor for additional prescriptions. The timing and prescriber's specialty are impacted by the indication for post-discharge opioids. The ORT did not predict which patients would receive post-discharge opioids. [ABSTRACT FROM AUTHOR]

Background: The present study aimed to assess the impact of perioperative fluid management on early acute kidney injury (AKI) rate and long-term sequelae in patients undergoing elective colorectal procedures within an enhanced recovery pathway (ERP). Methods: Retrospective analysis of consecutive patients from a prospectively maintained ERP database (2011–2015) is performed. Pre- and postoperative creatinine levels (within 24 h) were compared according to risk (preoperative creatinine rise ×1.5), injury (×2), failure (×3), loss of kidney function and end-stage kidney disease (RIFLE) criteria. Risk factors for early AKI were identified through logistic regression analysis, and long-term outcome in patients with AKI was assessed. Results: Out of 7103 patients, 4096 patients (58%) with pre- and postoperative creatinine levels were included. Of these, 104 patients (2.5%) presented postoperative AKI. AKI patients received higher amounts of POD 0 fluids (3.8 ± 2.4 vs. 3.2 ± 2 L, p = 0.01) and had increased postoperative weight gain at POD 2 (6 ± 4.9 vs. 3 ± 2.7 kg, p = 0.007). Independent risk factors for AKI were high ASA score (ASA ≥ 3: OR 1.7; 95% CI 1.1–2.5), prolonged operating time (>180 min: OR 1.9; 95% CI 1.3–2.9) and diabetes mellitus (OR 2.5; 95% CI 1.5–4), while minimally invasive surgery was a protective factor (OR 0.6; 95% CI 0.4–0.9). Five patients (0.1%) developed chronic kidney disease, and two of them needed dialysis after a mean follow-up of 33.7 ± 22.4 months. Conclusions: Early AKI was very uncommon in the present cohort of colorectal surgery patients treated within an ERP, and long-term sequelae were exceptionally low. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to analyze disease presentation, management, and oncological outcomes of patients diagnosed with peripartum colorectal cancer (CRC). Methods: Retrospective cohort study of all consecutive women of childbearing age (18–45 years) between 2002 and 2014 diagnosed with CRC adenocarcinoma at a tertiary academic institution. Patients who experienced pregnancy within 12 months of their diagnosis (peripartum period, group 1) were compared to the remaining patients of the cohort (group 2). Overall survival (OS) was compared between the two groups through Kaplan-Meier estimates. Results: Out of 555 consecutive women with a mean age of 37.8 + 6 years, 31 (5.6%) were diagnosed with CRC in the peripartum period. Of these, all patients were symptomatic during pregnancy due to bleeding, abdominal pain, or constipation; however, only 11 CRC (35.5%) were diagnosed during pregnancy, 1 (3.2%) during C section, and the remaining (61.3%) postpartum. TNM stage at presentation was I in 6 patients (19.4%), II in 4 patients (13.9%), III in 8 patients (25.8%), and IV in 13 patients (41.9%). Surgical resection was performed in 23 patients (74.2%): 2 while pregnant, 2 at the time of C section, and the remainder postpartum. Across all stages, OS was 95% at 1 year and 62% at 5 years and did not differ between the two comparative groups (p = 0.16). Conclusions: A suspicious attitude towards cancer-related symptoms during pregnancy is crucial to prevent delayed evaluation for CRC. [ABSTRACT FROM AUTHOR]

Purpose: Previous studies have shown that sphincter-preserving surgery is associated with better quality of life in postsurgical rectal cancer patients. However, the factors predicting the likelihood of undergoing sphincter-preserving surgery have not been well-described. The aim of this study was to report the factors that determined the likelihood of undergoing sphincter-preserving surgery.Methods: Characteristics of 24,018 rectal cancer patients undergoing sphincter-preserving surgery and abdominoperineal resection diagnosed from 2008 to 2012 from the National Cancer Database were investigated retrospectively for rate, pattern, and differences in mortality. Cox proportional hazards models were used to calculate hazard ratios for assessing mortality. Odds ratios were calculated using logistic regressions models for outcome sphincter-preserving surgery.Results: Eighteen thousand four hundred fifty-two (77%) patients had sphincter-preserving surgery. Majority of sphincter-preserving surgery patients were aged < 70 (74%), had private insurance (52%), and got treatment at a comprehensive community cancer program (54%). Multivariable analysis showed that patients with age ≥ 70 (OR 0.87, 95% CI 0.80-0.95), male gender (OR 0.90, 95% CI 0.84-0.96), having Medicare (OR 0.83, 95% CI 0.76-0.90), Medicaid (OR 0.72, 95% CI 0.63-0.81), and poorly differentiated grade (OR 0.78, 95% CI 0.71-0.85) were less likely to undergo sphincter-preserving surgery. Multivariable analysis showed that patients having abdominoperineal resection have higher likelihood of mortality than sphincter-preserving surgery (HR 1.26, 95% CI 1.16-1.36).Conclusions: We were able to identify several patient and tumor-related factors impacting the likelihood of undergoing sphincter-preserving surgery. Patients undergoing non-sphincter sparing surgery had a higher mortality that sphincter preservation. [ABSTRACT FROM AUTHOR]

Purpose: Enhanced recovery after surgery (ERAS) provides many benefits. However, important knowledge gaps with respect to specific components of enhanced recovery after surgery remain because of limited validation data. The aim of the study was to validate a mature ERAS protocol at a different hospital and in a similar population of patients.Methods: This is a retrospective analysis of patients undergoing elective colorectal surgery from 2009 through 2016. Patients enrolled in ERAS are compared with those undergoing the standard of care. Patient demographic characteristics, length of stay, pain scores, and perioperative morbidity are described.Results: Patients (1396) were propensity matched into two equal groups (ERAS vs non-ERAS). No significant difference was observed for age, Charlson Comorbidity Index, American Society of Anesthesiologists score, body mass index, sex, operative approach, and surgery duration. Median length of stay in ERAS and non-ERAS groups was 3 and 5 days (P < .001). Mean pain scores were lower in the ERAS group, measured at discharge from the postanesthesia unit (P < .001), on postoperative day 1 (P = .002) and postoperative day 2 (P = .02) but were identical on discharge.Conclusions: This ERAS protocol was validated in a similar patient population but at a different hospital. ERAS implementation was associated with an improved length of stay and pain scores similar to the original study. Different than most retrospective studies, propensity score matching ensured that groups were evenly matched. To our knowledge, this study is the only ERAS validation study in a propensity-matched cohort of patients undergoing elective colorectal surgery. [ABSTRACT FROM AUTHOR]

Background: Long-term oncologic outcomes after minimally invasive surgery (MIS) for rectal adenocarcinoma compared to open surgery continue to be debated. We aimed to review our high-volume single-institution outcomes in MIS rectal cancer surgery.Methods: A retrospective review of a prospectively collected database was completed of all consecutive adult patients with rectal adenocarcinoma treated from January 2005 through December 2011. Stage IV or recurrent disease was excluded. Demographics and operative and pathologic details were reviewed and reported. Primary endpoints include survival and recurrence.Results: A total of 324 patients were included and median follow-up was 54 months (IQR = 37.0, 78.8). The mean age was 58.2 ± 14.1 years. Tumors were in the upper rectum in 111 patients, mid-rectum in 113 patients, and lower rectum in 100 patients. Stage III disease was most common (49.4%). Overall conversion to open procedure rate was 13.9%. The circumferential radial margin was positive in only 1 patient (0.3%) and the mean lymph node yield was 24.7 ± 17.2. Cancer recurred in 42 patients (13%), 10 (2.5%) patients developed local recurrence, 32 (9.8%) developed distant metastasis, and 2 (0.6%) patients had both. The 5-year overall survival for stage 0, 1, 2, and 3 disease is 96, 91, 80, and 77%, respectively (p = 0.015).Conclusion: In carefully selected rectal cancer patients treated with MIS, long-term outcomes of survival and recurrence appear to compare favorably to previously published series. [ABSTRACT FROM AUTHOR]

Background: Ileal pouch anal anastomosis (IPAA) is associated with a high 30-day hospital readmission rate. Risk factors and etiology of readmission remain poorly defined. We sought to determine the 30-day hospital readmission rate following IPAA at a high-volume center and identify any modifiable perioperative factors.Methods: A retrospective review of all patients undergoing two- or three-stage IPAA for chronic ulcerative colitis at our institution between 2002 and 2013 was performed. Analysis was performed on rate of readmission, readmission diagnosis, intervention performed upon readmission, and risk factors for readmission.Results: Thirty-day primary and secondary readmission rates after IPAA were 20.3% (n = 185) and 2.1% (n = 19), respectively. The leading etiologies for readmission included partial small bowel obstruction/ileus (n = 52, 21.9%), pelvic sepsis (n = 43, 18.1%), dehydration (n = 42, 17.7%), and venous thromboembolism (n = 31, 13.1%). While the majority of readmissions were managed medically (n = 119, 65.4%), 19.2% (n = 35) required radiologic intervention and 15.3% (n = 28) required a return to the operating room. On univariate analysis, younger age (p = 0.03) and female sex (p = 0.04) had a significantly increased risk of readmission. On multivariable analysis, BMI ≥ 30 (OR 0.51; 95% CI, 0.25-0.97, p = 0.04) was protective of readmission.Conclusions: Thirty-day hospital readmission following IPAA remains a common problem. Preventable etiologies of readmission include dehydration and venous thromboembolism (VTE). Future quality improvement efforts should focus on education regarding stoma output and extended VTE prophylaxis to decrease hospital readmission rates following IPAA. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic ileal pouch-anal anastomosis (L-IPAA) has been increasingly adopted over the last decade due to short-term patient-related benefits. Several studies have shown L-IPAA to be equivalent to open IPAA in terms of safety and short-term outcomes. However, few L-IPAA studies have examined long-term functional outcomes. We aimed to evaluate the long-term functional outcomes of L-IPAA as compared to open IPAA.Methods: A previous case-matched cohort study at our institution compared short-term outcomes between L-IPAA and open IPAA from 1998 to 2004. For this study, we selected all patients from this case-matched cohort study with chronic ulcerative colitis (CUC) who had follow-up functional data of greater than 1 year. Functional data was obtained through prospective surveys, which were sent annually to all IPAA patients postoperatively.Results: One hundred and forty-nine patients (58 L-IPAA, 91 open IPAA) with a median 8-year duration of follow-up were identified. There were no differences in demographics and long-term surgical outcomes between groups. Stapled anastomosis was more common in the laparoscopic group (91.4 versus 54.9%, p < 0.001). Stool frequency during daytime (>6 stools, L-IPAA 32.8%, open 49.4%, p = 0.048) and nighttime (>2 stools, L-IPAA 13.8%, open 30.6%; p = 0.024) was significantly lower in the L-IPAA group. Ability to differentiate gas from stool was not different (p = 0.13). Rate of complete continence was similar in L-IPAA and open groups (L-IPAA 36.2%, open 21.8%, p = 0.060). There was no difference in use of medication to control stools, perianal skin irritation, voiding difficulty, sexual problems, and occupational change between groups. Subgroup analysis to evaluate for any group differences attributable to anastomotic technique demonstrated only that stapled anastomoses lead to more perianal skin irritation in the L-IPAA group (L-IPAA = 60.4% versus open IPAA = 38.8%; p = 0.031).Conclusion: Overall, L-IPAA has comparable functional results to the open approach with slightly lower daytime and nighttime stool frequency. This difference may be attributed to a greater number of stapled anastomoses performed in the laparoscopic cohort. [ABSTRACT FROM AUTHOR]

High-risk features are used to direct adjuvant therapy for stage II colon cancer. Currently, high-risk features are identified postoperatively, limiting preoperative risk stratification. We hypothesized carcinoembryonic antigen (CEA) can improve preoperative risk stratification for stage II colon cancer. The National Cancer Database (NCDB 2004-2009) was reviewed for stage II colon adenocarcinoma patients undergoing curative intent resection. A novel risk stratification including both traditional high-risk features (T4 lesion, <12 lymph nodes sampled, and poor differentiation) and elevated CEA was developed. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards analyzed overall survival. Concordance Probability Estimates (CPE) assessed discrimination. Seventy-four thousand nine hundred forty-five patients were identified; 40,844 (54.5%) had CEA levels reported and were included. Chemotherapy administration was similar between normal and elevated CEA groups (23.8 vs. 25.1%, p = 0.003). Compared to patients with CEA elevation, 5-year overall survival in patients with normal CEA was improved (74.5 vs. 63.4%, p < 0.001). Restratification incorporating CEA resulted in reclassification of 6912 patients (16.9%) from average to high risk. CPE increased for novel risk stratification (0.634 vs. 0.612, SE = 0.005). The routinely available CEA test improved risk stratification for stage II colon cancer. CEA not only may improve staging of colon cancer but may also help guide additional therapy. [ABSTRACT FROM AUTHOR]

Human jejunum smooth muscle cells (SMCs) and interstitial cells of Cajal (ICCs) express the SCN5A-encoded voltage-gated, mechanosensitive sodium channel NaV1.5. NaV1.5 contributes to small bowel excitability, and NaV1.5 inhibitor ranolazine produces constipation by an unknown mechanism. We aimed to determine the presence and molecular identity of Na+ current in the human colon smooth muscle and to examine the effects of ranolazine on Na+ current, mechano-sensitivity, and smooth muscle contractility. Inward currents were recorded by whole cell voltage clamp from freshly dissociated human colon SMCs at rest and with shear stress. SCN5A mRNA and NaV1.5 protein were examined by RT-PCR and Western blots, respectively. Ascending human colon strip contractility was examined in a muscle bath preparation. SCN5A mRNA and NaV1.5 protein were identified in human colon circular muscle. Freshly dissociated human colon SMCs had Na+ currents (-1.36 ± 0.36 pA/pF), shear stress increased Na+ peaks by 17.8 ± 1.8% and accelerated the time to peak activation by 0.7 ± 0.3 ms. Ranolazine (50 ixM) blocked peak Na+ current by 43.2 ± 9.3% and inhibited shear sensitivity by 25.2 ± 3.2%. In human ascending colon strips, ranolazine decreased resting tension (31%), reduced the frequency of spontaneous events (68%), and decreased the response to smooth muscle electrical field stimulation (61%). In conclusion, SCN5A-encoded NaV1.5 is found in human colonic circular smooth muscle. Ranolazine blocks both peak amplitude and mechanosensitivity of Na+ current in human colon SMCs and decreases contractility of human colon muscle strips. Our data provide a likely mechanistic explanation for constipation induced by ranolazine. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery pathways have been shown to improve short-term outcomes after colorectal surgery. Occurrence of complications can lead to prolonged length of stay (LOS). The goal of this study was to examine whether shorter time to occurrence of complications was associated with a shorter hospital LOS in rectal cancer patients undergoing minimally invasive surgery, taking into account the perioperative pathway. Study Design: This retrospective study included consecutive patients undergoing rectal cancer resection from 2005 to 2011 at a single institution. Enhanced recovery pathway was introduced in 2009. Complications and date of occurrence were reviewed. The impact of perioperative care modalities and comorbidities was evaluated using competing risk models with occurrence of complications and LOS as time-dependent outcomes measured as time from surgery. Results: A total of 346 patients were included in the analysis with 78 patients treated with enhanced recovery pathway, and 268 with established care. The overall complication rate was 22.3% (77 patients with ileus, wound infection, leak, abscess, small bowel obstruction, reoperation for bleeding, and renal failure). Median time to occurrence of a complication was 3 days post operation. The time to complication diagnosis was associated with shorter time to discharge after the advent of the complication (hazard ratio = 0.84; 95% CI, 0.73–0.96; p = 0.01). Enhanced recovery pathway was associated with a shorter LOS for patients without complications compared with the established pathway (hazard ratio = 2.81; 95% CI, 2.09–3.78; p < 0.001) after adjusting for comorbidities in a competing risk model. Conclusions: Early diagnosis of postoperative complications is associated with a shorter LOS after rectal cancer surgery. Enhanced recovery pathway can facilitate a faster recovery in the presence of comorbidities. [Copyright &y& Elsevier]