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Introduction: Presacral neuroendocrine neoplasms (PNENs) are rare tumors, with limited data on management and outcomes. Methods: A retrospective review of institutional medical records was conducted to identify all patients with PNENs between 2008 and 2022. Data collection included demographics, symptoms, imaging, surgical approaches, pathology, complications, and long-term outcomes. Results: Twelve patients were identified; two-thirds were female, averaging 44.8 years of age, and, for the most part, presenting with back pain, constipation, and abdominal discomfort. Preoperative imaging included computed tomography scans and magnetic resonance images, with somatostatin receptor imaging and biopsies being common. Half of the patients had metastatic disease on presentation. Surgical approach varied, with anterior, posterior, and combined techniques used, often involving muscle transection and coccygectomy. Short-term complications affected one-quarter of patients. Pathologically, PNENs were mainly well-differentiated grade 2 tumors with positive synaptophysin and chromogranin A. Associated anomalies were common, with tail-gut cysts prevalent. Mean tumor diameter was 6.3 cm. Four patients received long-term adjuvant therapy. Disease progression necessitated additional interventions, including surgery and various chemotherapy regimens. Skeletal, liver, thyroid, lung, and pancreatic metastases occurred during follow-up, with no mortality reported. Kaplan–Meier analysis showed a 5-year local recurrence rate of 23.8%, disease progression rate of 14.3%, and de novo metastases rate of 30%. Conclusion: The study underscores the complex management of PNENs and emphasizes the need for multicenter research to better understand and manage these tumors. It provides valuable insights into surgical outcomes, recurrence rates, and overall survival, guiding future treatment strategies for PNEN patients. [ABSTRACT FROM AUTHOR]

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]

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: 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 is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79 min vs. LECA: 143 ± 52 min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2 days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5 days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time. [ABSTRACT FROM AUTHOR]

Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in Crohn's disease (CD), and it is safe and feasible, even with severe penetrating CD or redo surgery. While MIS indications are continually broadening, challenging CD cases might still require an open approach. This study aimed to report rate and indications for an upfront open approach in ileocolic resection for CD. Comprehensive perioperative data for all consecutive patients undergoing ileocolic resection for CD between 2014 and 2021 in a high-volume referral center for CD and MIS, were collected retrospectively. Indications for an upfront open approach were reviewed separately by two authors according to the preoperative visit. Among 319 ileocolic resections for CD, 45 (14%) were open and 274 (86%) MIS. Two or more of the below indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p < 0.0001). Indications for upfront open approach were severe penetrating disease (58%), adhesions at previous surgery (47%), history of abdominal sepsis (33%), multifocal and extensive disease (24%), abdominal wall involvement (22%), concomitant open procedures (9%), small bowel dilatation (9%), and anesthesiologic contraindications (4%). MIS was never performed in a patient with abdominal wall involvement, concomitant open procedure, and anesthesiologic contraindication to MIS. This study can help guide patients, physicians, and surgeons. An abdominal wall involvement or the presence of two of the above indications predicts a high surgical complexity and may be considered as a no-go for the MIS approach. These criteria should prompt surgeons to strongly consider an upfront open approach to optimize the perioperative planning and care of these complex patients. [ABSTRACT FROM AUTHOR]

Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle – physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables – is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed. [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]

Magnetic resonance imaging (MRI) is routinely used for preoperative tumor staging and to assess response to therapy in rectal cancer patients. The aim of our study was to evaluate the accuracy of MRI based restaging after neoadjuvant chemoradiotherapy (CRT) in predicting pathologic response. This multicenter cohort study included adult patients with histologically confirmed locally advanced rectal adenocarcinoma treated with neoadjuvant CRT followed by curative intent elective surgery between January 2014 and December 2019 at four academic high‐volume institutions. Magnetic resonance tumor regression grade (mrTRG) and pathologic tumor regression grade (pTRG) were reviewed and compared for all the patients. The agreement between radiologist and pathologist was assessed with the weighted k test. Risk factors for poor agreement were investigated using logistic regression. A total of 309 patients were included. Modest agreement was found between mrTRG and pTRG when regression was classified according to standard five‐tier systems (k = 0.386). When only two categories were considered for each regression system, (pTRG 0‐3 vs pTRG 4; mrTRG 2‐5 vs mrTRG 1) an accuracy of 78% (95% confidence interval [CI] 0.73‐0.83) was found between radiologic and pathologic assessment with a k value of 0.185. The logistic regression model revealed that "T3 greater than 5 mm extent" was the only variable significantly impacting on disagreement (OR 0.33, 95% CI 0.15‐0.68, P =.0034). Modest agreement exists between mrTRG and pTRG. The chances of appropriate assessment of the regression grade after neoadjuvant CRT appear to be higher in case of a T3 tumor with at least 5 mm extension in the mesorectal fat at the pretreatment MRI. [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]

To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn's Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p < 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD. [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]

As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7 mL vs. 110.2 mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p = < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30 day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA). [ABSTRACT FROM AUTHOR]

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 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]

Despite an increasing trend towards utilization of minimally invasive approaches (MIS), results regarding their safety profile are contradictory. All patients who underwent elective colectomy for any underlying disease with an identifiable operative approach available from the targeted colectomy files of the ACS-NSQIP PUFs 2013 to 2018 were included. The trend of utilization and complication rates of the different operative approaches (open, laparoscopic, robotic) were assessed during the inclusion period. Furthermore, overall, surgical, and medical complications were compared between the three approaches. The study cohort included 78,987 patients. Of them, 12,335 (15.6%) patients underwent open, 57,874 (73.3%) laparoscopic, and 8,778 (11.1%) robotic surgery. There was an increasing trend towards the utilization of robotic surgery (2.5% increase per year) at the expense of the other approaches. With the increasing trend toward the utilization of the robotic approach, a decreasing trend in overall and surgical complications and length of stay was observed. After adjusting for the baseline confounders, robotic surgery was associated with shorter length of stay, lower rate of overall (OR 0.397; p < 0.05 compared to open and OR: 0.763; p < 0.05 compared to laparoscopy) and surgical complications (OR: 0.464; p < 0.05 compared to open and OR: 0.734; p < 0.05 compared to laparoscopy). This study revealed an increasing trend toward the utilization of MIS for elective colectomy in the US. Robotic surgery was associated with a decreasing trend in overall and surgical morbidity and length of stay. [ABSTRACT FROM AUTHOR]

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high‐risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high‐risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010‐2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)‐adjusted Kaplan‐Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high‐risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five‐year IPTW‐adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high‐risk pathological features showed an estimated 5‐year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high‐risk features that were treated with adjuvant chemotherapy. What's new? While adjuvant chemotherapy is associated with improved survival following curative resection for stage IIB‐C colon cancer with poor prognostic features, there is less consensus about the potential benefit of adjuvant treatment for patients with stage IIA disease. This propensity score analysis on a large cohort of stage IIA colon cancer patients shows that adjuvant chemotherapy can improve overall survival. Survival benefits were observed even among stage II patients with tumor growth into the outer lining of the colon wall (pathological T3 extent) and other high‐risk features, such as poor differentiation, invasion into perineural or lymphovascular tissues, or microsatellite instability. [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]

Objective: To determine the risk factors for developing primary postoperative pulmonary complications (PPC) in patients undergoing minimally invasive colorectal surgery (MIS) for the treatment of cancer and to identify the potential indicators for more extensive preoperative evaluation. Materials and methods: The ACS-NSQIP® database was interrogated to capture patients who had elective colon or rectal cancer and underwent MIS between 2012 and 2017. Patients who had primary PPC including pneumonia, unplanned intubation and/or failure to wean from mechanical ventilation for > 48 h were compared to patients without PPC. Significant risk factors for PPC were retained to build a predictive risk model through logistic regression analysis. The model was then internally validated using 2018 data. Results: Of 50,150 patients identified, 637 (1.3%) had PPC. The final risk prediction model included six variables: history of chronic obstructive pulmonary disease, age, smoking status, functional health status, pre-operative congestive heart failure, and American Society of Anesthesiology class ≥ 3. The model achieved good calibration (Hosmer–Lemeshow goodness-of-fit test, p = 0.614) and discrimination (c statistics = 0.757). Internal validation achieved similar discrimination (c statistics = 0.798). Conclusion: Primary postoperative pulmonary complications affected 1.3% of patients undergoing MIS for colon or rectal cancer. The novel predictive risk score showed good discrimination and may help to identify patients who may benefit from perioperative optimization. [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]

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]

Background Proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA. Methods A systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018. Results The frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%). Conclusion Pouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early. [ABSTRACT FROM AUTHOR]