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Background: Liver surgery is associated with a significant hospital stay regardless the type of liver resection. A large incision is essential for open liver surgery which is a major factor in the course of the patient’s recovery. For patients with small parenchyma liver lesions requiring surgical resection, robotic surgery potentially offers the opportunity to transform the patient’s post-operative course. A day-case robotic liver resection pathway was formulated and implemented at our institution when patients were planned for discharge within 24 h of admission for liver surgery. Methods: Single surgeon case series of cases performed at a tertiary hepatobiliary and pancreatic centre between September 2022 and November 2023. The inclusion criteria were non-anatomical wedge resections, < 2 anatomical segmental resections, left lateral hepatectomy and minimally invasive surgery. Results: This is the first series of robotic day-case minor liver resection in the United Kingdom. 20 patients were included in this case series. The mean operative time was 86.6 ± 30.9 min and mean console time was 58.6 ± 24.5 min. Thirteen patients (65%) were discharged within 24 h of surgery. The main cause of hospitalisation beyond 24 h was inadequate pain relief. There were no Clavien–Dindo grade III or above complications, no 30-day readmission and 90-day mortalities. Conclusion: This case series demonstrates that robotic day-case liver resection is safe and feasible. Robust follow-up pathways must be in place to allow for the safe implementation of this approach, to monitor for any complications and to allow intervention as required in a timely manner.

Abstract: PURPOSE: The present study evaluated the effect of rectal washout in reducing local recurrence after resection for rectal cancer. METHODS: A literature search was performed on studies published since 1989 that compared rectal washout to no washout for rectal cancer resection. Primary end point was local cancer recurrence. Random-effect meta-analysis was used and subgroup analysis was performed. RESULTS: Five studies matched the selection criteria, and reported on 176 patients who underwent rectal washout and 256 who did not undergo washout. Different washout solutions were used in every study, and total mesorectal excision was not universally applied. Overall local recurrence rate was 8 percent (33/432). Local recurrence rate for rectal washout patients was 4.8 percent compared with 10.2 percent for patients who did not undergo rectal washout, a difference that was not statistically significant (odds ratio = 0.64; 95 percent confidence interval = 0.2–2.04). When only studies using total mesorectal excision were considered, there was no significant difference between the two groups (odds ratio = 1.21; 95 percent confidence interval = 0.37–3.92). CONCLUSIONS: Although no definitive conclusions may be drawn because of the nonrandomized nature of the included studies, rectal washout is relatively risk-free and adds little to the operative time. This may be performed until a randomized, controlled trial is undertaken to resolve this contentious issue.

Surgery for ileocolonic Crohn’s disease can result in temporary or permanent stoma formation which can be associated with morbidity as parastomal and incisional hernias, readmissions due to obstruction or high stoma output, and have a negative impact on quality of life. We propose an international retrospective trainee-led study of the outcomes of temporary stomas in patients with Crohn’s disease. We aim to evaluate both the short-term (6 month) and mid-term (18 month) outcomes of temporary stomas in patients with Crohn’s Disease. Retrospective, multicentre, observational study including all patients who underwent elective or emergency surgery for ileal, colonic and ileocolonic Crohn’s disease during a 4-year study period. Primary outcome is the proportion of patients who still have an ileostomy or colostomy 18 months after the initial surgery. Secondary outcomes: complications related to stoma formation and stoma reversal surgery; time interval between stoma formation and stoma reversal; risk factors for stoma formation and non-reversal of the stoma. We present the study protocol for a trainee-led, multicentre, observational study. Previous research has demonstrated significant heterogeneity surrounding the formation and the timing of reversal surgery in patients having a temporary ileostomy following colorectal cancer surgery, highlighting the need to address these same questions in Crohn’s disease, which is the aim of our research.

Background: There is no clear consensus about the best surgical strategy for patients with colorectal cancer (CRC) and synchronous liver metastases (SCRLM). Methods: Between 2009 and 2019, patients with CRC and SCRLM considered for curative treatment were included. Perioperative and follow-up data were analysed to examine the safety and survival outcomes of primary first (PF), liver first (LF) and simultaneous resection (SR) strategies. Results: 204 patients were identified, consisting of PF (n= 129), LF (n= 26) and SR (n= 49). Forty-five patients (22.1%) failed to have either the primary or the liver metastases resected following initial LF (n= 11, 42.3%) or PF (n= 34, 26.4%), respectively (p< 0.001). The postoperative morbidity rates were 31.0%, 38.4% and 40.8% in PF, LF and SR group, respectively (p= 0.409); the mortality rates were 2.3%, 0% and 4.1%, respectively (p= 0.547). The 1-, 3- and 5-year overall survival (OS) were 94%, 72%, 53% in the PF group, 74%, 54%, 36% in the LF group, and 91%, 74%, 63% in the SR group. LF group had the worst OS compared to PF and SR (p= 0.040, p= 0.052). The 1-, 3- and 5-year disease-free survival (DFS) were 31%, 15%, 10% in PF, 21%, 9% and 9% in LF and 45%, 28% and 28% in SR group, respectively. SR group had a better DFS compared to PF and LF (p= 0.005, p= 0.008). At the multivariate analysis, there was no difference between the three strategies in terms of OS (PF vs SR OS-HR 1.090, p= 0.808; LF vs SR OS-HR 1.582, p= 0.365) and the PF had a worse DFS compared to the SR approach (PF vs SR DFS-HR 1.803, p= 0.007; LF vs SR DFS-HR 1.252, p= 0.492). Conclusions: PF, LF and SR had comparable postoperative morbidity and mortality. The three surgical strategies had similar OS outcomes. The PF strategy was associated with a worse DFS than SR, while the LF approach was associated with a high failure rate to progress to the second stage (primary tumour resection).

The outbreak of the COVID-19 pandemic produced unprecedented challenges, at a global level, in the provision of cancer care. With the ongoing need in the delivery of life-saving cancer treatment, the surgical management of patients with colorectal cancer required prompt significant transformation. The aim of this retrospective study is to report the outcome of a bespoke regional Cancer Hub model in the delivery of elective and essential colorectal cancer surgery, at the height of the first wave of the COVID-19 pandemic. 168 patients underwent colorectal cancer surgery from April 1st to June 30th of 2020. Approximately 75% of patients operated upon underwent colonic resection, of which 47% were left-sided, 34% right-sided and 12% beyond total mesorectal excision surgeries. Around 79% of all resectional surgeries were performed via laparotomy, and the remainder 21%, robotically or laparoscopically. Thirty-day complication rate, for Clavien–Dindo IIIA and above, was 4.2%, and 30-day mortality rate was 0.6%. Re-admission rate, within 30 days post-discharge, was 1.8%, however, no patient developed COVID-19 specific complications post-operatively and up to 28 days post-discharge. The established Cancer Hub offered elective surgical care for patients with colorectal cancer in a centralised, timely and efficient manner, with acceptable post-operative outcomes and no increased risk of contracting COVID-19 during their inpatient stay. We offer a practical model of care that can be used when elective surgery “hubs” for streamlined delivery of elective care needs to be established in an expeditious fashion, either due to the COVID-19 pandemic or any other future pandemics.

ObjectivesAnal squamous cell carcinoma (ASCC) is an uncommon cancer that is rapidly increasing in incidence. HIV is a risk factor in the development of ASCC, and it is thought that the rapidly increasing incidence in men is related to increasing numbers of people living with HIV (PLWH). We undertook a population-based study comparing the demographics and incidence of ASCC in patients residing high HIV prevalence areas in England to patients living in average HIV prevalence areas in England.MethodsThis is a cross-sectional study following the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ statement. Demographic data and incidence rates of ASCC within Clinical Commissioning Groups (CCGs) between 2013 and 2018 were extracted from the Cancer Outcomes and Services Dataset. CCGs were then stratified by HIV prevalence from data given by Public Health England, and high HIV prevalence geographical areas were compared with average HIV geographical areas.ResultsPatients in high HIV areas were more likely to be young and male with higher levels of social deprivation. Incidence rates in men between 2013 and 2017 were higher in high HIV areas than average HIV areas with a rapidly increasing incidence rates in early-stage disease and a 79.1% reduction in incidence of metastatic stage 4 disease.Whereas women in high HIV areas had lower ASCC incidence than the national average and a low incidence of early-stage disease; however, metastatic disease in women had quintupled in incidence in high HIV areas since 2013.ConclusionsPatients presenting with ASCC in high HIV geographical areas have different demographics to patients presenting in average HIV geographical areas. This may be related to screening programmes for PLWH in high HIV areas.

IMPORTANCE: The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer. OBSERVATIONS: Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts. CONCLUSIONS AND RELEVANCE: The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.

Outcomes of inflammatory bowel disease (IBD) patients requiring surgery during the outbreak of Coronavirus disease 19 (COVID-19) are unknown. Aim of this study was to analyse the outcomes depending on the COVID-19 status of the centre. Patients undergoing surgery in six COVID-19 treatment and one COVID-free hospitals (five countries) during the first COVID-19 peak were included. Variables associated with risk of moderate-to-severe complications were identified using logistic regression analysis. A total of 91 patients with Crohn’s disease (54, 59.3%) or ulcerative colitis (37, 40.7%), 66 (72.5%) had surgery in one of the COVID-19-treatment hospitals, while 25 (27.5%) in the COVID-19-free centre. More COVID-19-treatment patients required urgent surgery (48.4% vs. 24%, p= 0.035), did not discontinue biologic therapy (15.1% vs. 0%, p= 0.039), underwent surgery without a SARS-CoV-2 test (19.7% vs. 0%, p= 0.0033), and required intensive care admission (10.6% vs. 0%, p= 0.032). Three patients (4.6%) had a SARS-CoV-2 infection postoperatively. Postoperative complications were associated with the use of steroids at surgery (Odds ratio [OR] = 4.10, 95% CI 1.14–15.3, p= 0.03), presence of comorbidities (OR = 3.33, 95% CI 1.08–11, p= 0.035), and Crohn’s disease (vs. ulcerative colitis, OR = 3.82, 95% CI 1.14–15.4, p= 0.028). IBD patients can undergo surgery regardless of the COVID-19 status of the referral centre. The risk of SARS-CoV-2 infection should be taken into account.

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Colorectal cancer (CRC) is the third cause of cancer-related death worldwide. It has been estimated that more than one million new cases occur every year. Several studies have investigated the role of host bacteria as agents protecting against or increasing the risk of CRC, but few have assessed the fungal microbiome in patients with CRC. Fungal dysbiosis has been studied in colorectal diseases (e.g. inflammatory bowel diseases), but few researches compared the fungal microbiome of CRC patients with those of controls. The current study represents a systematic review aimed at assessing the expression and diversity of fungi in patients with CRC and non-CRC individuals. Here, we discuss the fungal species that could be implied in CRC development and alterations that can be induced by the presence of CRC, and the potential implications for future research.

Unplanned readmissions heavily affect the cost of health care and are used as an indicator of performance. No clear data are available regarding beyond-total mesorectal excision (bTME) procedure. Aim of the study is to identify patient-related and surgery-related factors influencing the 30-day readmissions after bTME. Retrospective data were collected from 220 patients who underwent bTME procedures at single centre between 2006 and 2016. Patient-related and operative factors were assessed, including body mass index (BMI), age, gender, American Society of Anaesthesiologists’ (ASA) score, preoperative stage, neo-adjuvant therapy, primary tumour vs recurrence, the extent of surgery. The readmission rate was 8.18%. No statistically significant association was found with BMI, ASA score, length of stay and stay in the intensive care unit, primary vs recurrent tumour or blood transfusions. Not quite statistically significant was the association with pelvic side wall dissection (OR 3.32, p= 0.054). Statistically significant factors included preoperative stage > IIIb (OR: 4.77, p= 0.002), neo-adjuvant therapy (OR: 0.13, p= 0.0006), age over 65 years (OR: 5.96, p= 0.0005), any re-intervention during the first admission (OR: 7.4, p= 0.0001), and any post-operative complication (OR: 9.01, p= 0.004). The readmission rate after beyond-TME procedure is influenced by patient-related factors as well as post-operative morbidity.

Earlier detection of colorectal cancer (CRC) results in improved survival. Existing non-invasive biomarkers have suboptimal accuracy. Neurotensin (NTS) is involved in CRC carcinogenesis. This study evaluated the diagnostic potential of plasma NTS for colorectal polyps and cancers. Participants were selected based on national CRC referral guidelines. All subjects underwent colonoscopy. Average plasma concentrations were compared across different diagnostic groups. Predictors for detecting colorectal neoplasia were identified. Receiver operator characteristic (ROC) curve analysis assessed the diagnostic accuracy of NTS. An independent biobank was used as validation group. Of 165 participants, 46 had polyps or CRC. Significantly higher plasma NTS was found in the colonic neoplasia group (603.6 pg/ml vs. 407.2 pg/ml, p< 0.01). Risk factors for colonic polyps or cancers included Loge(plasma NTS concentration) (OR, 2.73; 95% CI, 1.33–5.59, p< 0.01), loge(Age) (OR, 15.49; 95% CI, 2.67–89.66, p< 0.01) and cigarette smoking (OR, 3.49; 95% CI, 1.31–9.26, p= 0.01). Plasma NTS had an optimal sensitivity of 60.4% and specificity of 71.6% for the diagnosis of colorectal polyps and cancers. Similar diagnostic accuracy was obtained in the validation group. Plasma NTS has the potential to be a non-invasive biomarker for colorectal neoplasia. It appears to be more accurate than existing blood markers and is unique in being able to detect precancerous polyps.

The objective is to investigate preoperative body mass index (BMI) in patients receiving beyond total mesorectal excision (bTME) surgery. The primary end point is length of postoperative stay. Secondary end points are length of intensive care stay, postoperative morbidity and overall survival. BMI is the most commonly used anthropometric measurement of nutrition and studies have shown that overweight and obese patients can have improved surgical outcomes. Patients who underwent a bTME operation for locally advanced or recurrent rectal cancer were put into three BMI (kg/m2) groups of normal weight (18.5–24.9), overweight (25–29.9) and obese (≥ 30) for analysis. Included are 220 consecutive patients from a single centre. The overall length of stay, in days ± standard deviation (range), for normal weight, overweight and obese patients was 21.14 ± 16.4 (6–99), 15.24 ± 4.3 (7–32) and 19.10 ± 9.8 (8–62) respectively (p= 0.002). The mean ICU length of stay was 5.40 ± 9.1 (1–69), 3.37 ± 2.4 (0–19) and 3.60 ± 2.4 (1–14), respectively (p= 0.030). There was no significant difference between the three groups in terms of postoperative morbidity or overall survival. Patients with a normal weight BMI in this cohort have a significantly longer length of stay in ICU and in hospital than overweight or obese patients. This is seen with no significant difference in morbidity or overall survival.

AbstractAim:To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults.Methods:A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI.Results:The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQTMversus Durasphere®. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions.Conclusions:The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.

Abdominal salvage surgery is a major undertaking for patients with imminent ileal pouch failure. The success of abdominal salvage surgery for sepsis is less than for a nonseptic indication. Although functional outcomes following abdominal revisional surgery can improve significantly, pouch failure after abdominal salvage continues steadily over time. Complications may occur and the duration of treatment, including in-hospital stay, may have a serious impact on a patient who has already suffered disappointment and ill health owing to the threatened failure after primary restorative proctocolectomy. The chance of success is an essential part of the consultation process and must be discussed fully.

MR defecography (MRD) is an alternative to conventional defecography (CD) which allows for dynamic visualisation of the pelvic floor. The aim of this study was to assess whether MRI features indicative of pelvic floor dysfunction correlated with patient-reported symptom severity. MR proctograms were matched to a prospectively-maintained functional database. Univariate and multivariate analyses were performed using pre-treatment questionnaire responses to the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score (WIS), and modified Obstructed Defecation Symptom (ODS) Score. 302 MRI proctograms were performed between January 2012 and April 2015. 170 patients were included. Patients with a rectocele > 2 cm (p= 0.003; OR 5.756) or MRD features suggestive of puborectalis syndrome (p= 0.025; OR 8.602) were more likely to report a higher ODS score on multivariate analysis. Lack of rectal evacuation was negatively associated with an abnormal WIS (p= 0.007; OR 0.228). Age > 50 (p= 0.027, OR 2.204) and a history of pelvic floor surgery (p= 0.042, OR 0.359) were correlated with an abnormal BBUSQ incontinence score. Lack of rectal evacuation (p= 0.027, OR 3.602) was associated with an abnormal BBUSQ constipation score. Age > 50 (p= 0.07, OR 0.156) and the presence of rectoanal intussusception (p= 0.010, OR 0.138) were associated with an abnormal BBUSQ evacuation score. Whilst MRD is a useful tool in aiding multidisciplinary decision making, overall, it is poorly correlated with patient-reported symptom severity, and treatment decisions should not rest solely on results.

AbstractMixed adenoneuroendocrine carcinoma (MANEC) are rare cancers of the gastrointestinal (GI) and pancreatobiliary tract. They are characterized by the presence of a combination of epithelial and neuroendocrine elements, where each component represents at least 30% of the tumour. Review of literature and consolidation of clinicopathological data. Sixty-one cases of colorectal MANEC have been reported in literature and one seen in this centre. The median age of the patients affected was 61.9 ± 12.4 years (20–94 years). Male to female ratio is 1.0:1.2. Presentations were similar to other colorectal malignancies. 58.0% of colorectal MANECs were found in the right colon, 8.1% cases in the transverse, 16.1% in the left colon, 16.1% in the rectum. These tumours appeared invasiveness 79.1% were T3–T4. Over 90% of cases were presented with metastatic disease. The majority of patient underwent surgical resection of the primary cancer (96.6%). Of these, 10 operations (17.9%) were emergency operations due to obstruction, perforation, or bleeding. Three patients received first line palliative care. In eight cases (13.8%), patients underwent adjuvant chemotherapy. The median overall survival after diagnosis was 10 ± 2.4 months (95% CI: 5.37–14.64 months). MANECs are rare but aggressive colorectal cancers. Surgical resection of localized disease with adjuvant chemotherapy appears to significantly improve survival in small case series. Further understanding through the sharing of experiences is required.

Faecal incontinence is a common complication of ileal pouch anal anastomosis (IPAA) and seems to worsen with time. The aim of this paper is to review the evidence of the use of sacral nerve stimulation (SNS) for patients with faecal incontinence after IPAA. A literature search was performed on PubMed and Cochrane databases for all relevant articles. All studies, which reported the outcome of SNS in patients with faecal incontinence after IPAA, were reviewed. Three papers were identified, including a case report, cohort study and retrospective study. The total number of patients was 12. The follow-up duration included 3 months, 6 months and 24 months. After peripheral nerve evaluation, definitive implantation was performed in 10 (83.3%) patients. All three studies reported positive outcomes, with CCF scores and incontinence episodes improving significantly. Preliminary results suggest good outcome after permanent SNS implant. Studies with larger sample sizes, well-defined patient characteristics and standardized outcome measures are required to fully investigate the effect of SNS in IPAA patients.

Adequate oncological outcomes have been demonstrated with rectal resection and handsewn coloanal anastomosis (CAA) in tumours in close proximity to the internal anal sphincter. Our aim was to assess functional differences between handsewn CAA and ultralow stapled anastomosis. Participants were identified from a single-surgeon series. Included participants underwent anorectal physiology testing of anal sphincter function, in addition to completion of several questionnaires: Wexner Incontinence Score (WIS); Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ); Low Anterior Resection Syndrome (LARS) Score; SF36. Non-parametric data compared using the Mann–Whitney Utest. 20 participants were included; 11 stapled and 9 handsewn. Mean follow-up was 2.95 ± 1.97 years. The mean LARS score was 21.9 ± 1.97 years in the stapled group versus 29.4 ± 9.57 in the handsewn group (p= 0.133). The Wexner incontinence score was significantly higher in the handsewn group (p= 0.0076), with a mean score of 4.6 ± 3.69 versus 10.9 ± 4.76. The incontinence domain of the BBUSQ was also significantly worse in patients with a handsewn anastomosis (p= 0.001). With the exception of general health (p= 0.035) and social functioning (p= 0.035), which were worse in the handsewn groups, the other six domains of the SF-36 showed no statistical difference between groups. Anorectal physiology scores were not significantly different. Handsewn CAA anastomosis is known to be safe and oncologically feasible. Patient selection should be vigorous, with preoperative counseling regarding the likelihood of incontinence to manage patients’ expectations and promote comparable quality of life in the long-term.

AbstractBackground:Anorectal manometry (ARM) is conventionally used to assess patients with fecal incontinence (FI). This review aims to establish the diagnostic accuracy of ARM for FI.Method:A search of MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library was performed. Studies examining the sensitivity and specificity of ARM measures, either individually or combined, in the diagnosis of FI, were included. Data analysis was conducted using the bivariate statistical method.Results:Seven studies were included out of an initial search of 1499 studies. The summary sensitivity and specificity for ARM as an overall test were 0.80 (95% confidence interval (CI): 0.69–0.88) and 0.80 (95% CI: 0.65–0.90), respectively. The diagnostic odds ratio (DOR) for ARM was found to be 16.61 (95% CI: 5.52–50.03). The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) for ARM were found to be 4.09 (95% CI: 2.11–7.94) and 0.25 (95% CI: 0.14–0.42), respectively. Subgroup analysis based on four studies reporting on maximum resting pressure (MRP) demonstrated a sensitivity, specificity, DOR, PLR and NLR of 0.60 (95% CI: 0.38–0.79), 0.93 (95% CI: 0.80–0.97), 20.0 (95% CI: 4.00–91.00), 8.60 (95% CI: 3.00–24.30) and 0.43 (95% CI: 0.24–0.76), respectively.Conclusion:ARM has been shown to be an accurate test for diagnosing FI. Further studies are required to establish the diagnostic accuracy of individual ARM measures.

AbstractBackground:Colorectal Cancer (CRC) is a disease of the elderly, and with an ageing population, oncological surgical procedures for CRC in the elderly is expected to increase. However, the balance between surgical benefits and risks associated with age and comorbidities in elderly patients is obscure.Materials and methods:A retrospective database of consecutive patients who received CRC surgery was used to compare short-term surgical and oncological outcomes between patients aged ≥75 and <75 years old undergoing CRC resection.Results:There were 54 patients (63.5%) in the <75 group and 31 patients (36.5%) in the ≥75 group. Overall, there were no differences between the <75 and ≥75 groups in postoperative HDU/ITU stay, median hospital LOS or 30-day mortality rates. Patients ≥75 had a higher preoperative performance status (25.9% versus 71.0%, p < .001), but no difference in ASA Grade and referral pattern, proportion of emergency operations, cancer staging, resection margins, achievement of curative resection or median lymph node yield. There was a significantly higher use of adjuvant chemotherapy in the <75 age group (48.1% versus 25.8%, p = .043).Conclusions:With adequate patient selection, CRC resection in elderly patients is not associated with higher postoperative mortality or worse short-term oncological benefits.

There is an ever-growing need, with the ongoing developments in research and the progress towards patient centered care, to delineate standardized protocols of management of anal cancer. However, guidelines from different societies show some degree of disagreement. This is a systematic review of the literature to identify similarities and discrepancies between the guidelines for the management of anal cancer drafted by the European Society for Medical Oncology (ESMO) and by the National Comprehensive Cancer Network (NCCN). We found essentially similar management for investigation, diagnosis, chemotherapy regimens, and radiotherapy doses in both ESMO and NCCN recommendations in the management of anal cancer. There were few differences, which included the levels of evidence and grades of recommendations, the delineation of radiotherapy fields, and the treatment of the elderly and personalized medicine based on genetics. The follow-up regime is also marginally different in the first 2 years. Even if the observed differences may be justified by a different implementation of evidence-based medicine among different countries for particular management modalities of anal cancer, we identified the grey areas which need further study. In addition, these facets should be assessed more carefully when planning future guidelines.

Colorectal cancer screening programs aim at early detection of cancer to reduce incidence rates and mortality. The objective of this study is to identify the role of neurotensin in the endoscopic screening of high-risk population for developing colorectal neoplasia. Blood samples from patients referred for urgent colonoscopy to investigate symptoms suspicious of colorectal cancer were collected. Blood neurotensin levels were measured using enzyme-linked immunosorbent assay. Colonoscopy findings were used as reference for determining the diagnostic accuracy of blood neurotensin. The study comprised 26 patients in total: 12 healthy and 14 with colon pathology (13 high-grade dysplasia adenomatous polyps, 1 adenocarcinoma). There were no statistically significant differences in the clinical and biochemical parameters between colon pathology and healthy group except neurotensin levels. Pathology in colon was associated with 3.7-fold increase in NT levels. In multivariate analysis, patients with pathology in colon have increased serum neurotensin levels compared to controls adjusted for age, gender, BMI and co-morbidities. The value of 12.93 pg/ml is associated with 87.5% sensitivity and 91.7% specificity for discriminating the colon pathology from normal colonic epithelium (p= 0.001). Neurotensin plasma values differentiate healthy people from patients suffering from colonic pathologies such as adenomatous polyps and cancer. The use of neurotensin as a potential endoscopic screening tool for identifying high-risk population for developing colorectal cancer is promising, but much has to be done before it is validated in larger scale prospective studies.

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This pilot study assessed the diagnostic accuracy of rapid evaporative ionization mass spectrometry (REIMS) in colorectal cancer (CRC) and colonic adenomas. Patients undergoing elective surgical resection for CRC were recruited at St. Mary’s Hospital London and The Royal Marsden Hospital, UK. Ex vivo analysis was performed using a standard electrosurgery handpiece with aspiration of the electrosurgical aerosol to a Xevo G2-S iKnife QTof mass spectrometer (Waters Corporation). Histological examination was performed for validation purposes. Multivariate analysis was performed using principal component analysis and linear discriminant analysis in Matlab 2015a (Mathworks, Natick, MA). A modified REIMS endoscopic snare was developed (Medwork) and used prospectively in five patients to assess its feasibility during hot snare polypectomy. Twenty-eight patients were recruited (12 males, median age 71, range 35–89). REIMS was able to reliably distinguish between cancer and normal adjacent mucosa (NAM) (AUC 0.96) and between NAM and adenoma (AUC 0.99). It had an overall accuracy of 94.4 % for the detection of cancer versus adenoma and an adenoma sensitivity of 78.6 % and specificity of 97.3 % (AUC 0.99) versus cancer. Long-chain phosphatidylserines (e.g., PS 22:0) and bacterial phosphatidylglycerols were over-expressed on cancer samples, while NAM was defined by raised plasmalogens and triacylglycerols expression and adenomas demonstrated an over-expression of ceramides. REIMS was able to classify samples according to tumor differentiation, tumor budding, lymphovascular invasion, extramural vascular invasion and lymph node micrometastases (AUC’s 0.88, 0.87, 0.83, 0.81 and 0.81, respectively). During endoscopic deployment, colonoscopic REIMS was able to detect target lipid species such as ceramides during hot snare polypectomy. REIMS demonstrates high diagnostic accuracy for tumor type and for established histological features of poor prognostic outcome in CRC based on a multivariate analysis of the mucosal lipidome. REIMS could augment endoscopic and imaging technologies for precision phenotyping of colorectal cancer.

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Dans la prise en charge des adénocarcinomes du rectum non métastatiques, la question de l’intérêt d’une chimiothérapie adjuvante chez les patients ayant une stérilisation ganglionnaire après radiochimiothérapie néoadjuvante reste posée, notamment les patients ypT3N0. Le but de cette étude était d’évaluer l’intérêt d’une chimiothérapie adjuvante chez les patients ypT3N0 ayant une stérilisation ganglionnaire après radiochimiothérapie néoadjuvante.

SUMMARYVenous invasion has been considered a poor prognostic factor in rectal cancer for over half a century. This term has evolved in recent years and now applies specifically to tumor invasion into extramural veins – extramural venous invasion. This distinction from intramural venous invasion is important as it is more clinically relevant. Extramural venous invasion can be identified by histopathology and MRI but until recently there has been a lack of consistency in definitions and detection techniques. This paper reviews the historical evidence for the prognostic importance and detection of venous invasion in rectal cancer.

A meta-analysis of published literature comparing outcomes after laparoscopic resection (LR) with open resection (OR) for transverse colon tumours. Medline, PubMed, CINAHL, EMBASE and Cochrane were searched from inception to October 2013. The text words “minimally invasive”, “keyhole surgery” and “transverse colon” were used in combination with the medical subject headings “laparoscopy” and “colon cancer”. Outcome variables were chosen based upon whether the included articles reported results. A meta-analysis was performed to obtain a summative outcome. Six comparatives involving 444 patients were analysed. Of them 245 patients were in the LR group and 199 in the OR group. There was a significant increase in operative time in the LR group compared with the OR group [random effects model: SMD = −0.65, 95 % CI (−1.01, −0.30), z= −3.60, p< 0.001] but there was significant heterogeneity amongst trials (Q= 15.51, df= 5, p= 0.008, I2= 68). There was less blood loss in the LR group [fixed effects model: SMD = 0.70, 95 % CI (0.47, 0.93), z= 6.01, p< 0.001] and patients returned to oral diet earlier [random effects model: SMD = 0.78, 95 % CI (0.40, 1.16), z= 4.01, p< 0.001] and had a reduced time to functioning bowel [fixed effects model: SMD = 0.86, 95 % CI (0.60, 1.11), z= 6.63, p< 0.001]. No difference was seen for overall morbidity (p= 0.76) or mortality (p= 0.58). LR of transverse colon tumours is a safe and effective technique. Although there is an increase in operating time, operative and clinical outcomes of intraoperative blood loss and faster recovery are seen with laparoscopic procedures.

The learning curve for laparoscopic colorectal surgery has not been conclusively analyzed. No reliable framework for case selection during training is available.

In rectal cancer, the standard of care after the completion of radiotherapy is surgery at 6 to 8 weeks. However, there is variation regarding the timing of surgery.

Spigelian hernias are rare, and their treatment has traditionally been by open surgery. Laparoscopic management is however, becoming more popular. The aim of our review is to examine the existing evidence regarding the safety and effectiveness of the laparoscopic approach to the management of spigelian hernias.

HYPOTHESIS A model could be developed to identify patients who can safely undergo restorative proctocolectomy (RPC) without proximal diversion. DESIGN Logistic regression analysis was used to identify independent factors favoring omission of ileostomy at the time of RPC. A propensity nomogram was developed and validated using measures of calibration, discrimination, and subgroup analysis. SETTING Two tertiary referral centers. PATIENTS A total of 4013 patients undergoing RPC between January 1977 and December 2005 were included in the study sample. MAIN OUTCOME MEASURE The decision to omit loop ileostomy at the time of RPC. RESULTS After study group exclusions, proximal diversion was performed in 3196 of 3733 patients (85.6%) undergoing RPC; 45.4% of 3733 patients were women. The mean (SD) age at surgery was 37.4 (12.8) years. Ulcerative colitis was the indication for RPC in 2304 patients (61.7%) and familial adenomatous polyposis in 364 patients (9.8%), and a J pouch was performed in 2657 patients (71.2%). The following were found to be associated with ileostomy omission: stapled anastomosis (odds ratio [OR], 6.4), no preoperative corticosteroid use (OR, 3.2), familial adenomatous polyposis diagnosis (OR, 2.6), cancer diagnosis (OR, 3.4), female sex (OR, 1.6), and age at surgery younger than 26 years (OR, 2.1) (P &lt; .01 for all). The model discriminated well (area under the receiver operating characteristic curve, 74.9%), with no significant differences between observed and expected outcomes (P = .49). Omission of proximal diversion demonstrated no significant effect on postoperative adverse events, although it was associated with a 2-day increase in the median length of hospital stay (P &lt; .01). CONCLUSION Incorporation of a 5-point nomogram in the preoperative assessment of patients undergoing RPC may aid clinicians in identifying a select group of patients who may be candidates for ileostomy omission during RPC.Arch Surg. 2011;146(1):82-88--

This study used meta-analytical techniques to compare the recurrence of granulomatous vs nongranulomatous Crohn disease.

Circumferential resection margin involvement after rectal cancer surgery is associated with local recurrence and decreased survival, but definitions of “safe” margins vary. This study assessed the influence of various circumferential margins on long-term outcome from rectal cancer surgery.

This study was designed to compare outcomes after elective laparoscopic and conventional colorectal surgery over a ten-year period using data from the English National Health Service Hospital Episode Statistics database.

This study was designed to assess the impact of social deprivation on rates of abdominoperineal excision of the rectum in the United Kingdom.

Abdominal salvage surgery is a major undertaking for patients with imminent ileal pouch failure. The success of abdominal salvage surgery for sepsis is less than for a nonseptic indication. Although functional outcomes following abdominal revisional surgery can improve significantly, pouch failure after abdominal salvage continues steadily over time. Complications may occur and the duration of treatment, including in-hospital stay, may have a serious impact on a patient who has already suffered disappointment and ill health owing to the threatened failure after primary restorative proctocolectomy. The chance of success is an essential part of the consultation process and must be discussed fully.

The aim of this study was to evaluate clinical outcomes, quality-adjusted life-years, and the cost-effectiveness gained from percutaneous drainage followed by elective surgery vs.initial surgery for abdominopelvic abscesses related to Crohn's disease.

Pouchitis following restorative proctocolectomy is common. Inflammation proximal to the pouch, prepouch ileitis (PPI) has recently been described. Its incidence and implications are unknown. The aim of this study was to identify the incidence of PPI at pouchoscopy and correlate this with symptoms, diagnosis, and outcome.

This study was designed to investigate sexual and urinary dysfunction in women who underwent rectal cancer excision, and the influence of tumor and treatment variables on long-term outcomes.

OBJECTIVE To compare outcomes following abdominal surgery with or without the use of chewing gum in the early postoperative period. DATA SOURCES MEDLINE, Embase, Ovid, and Cochrane databases. STUDY SELECTION Randomized controlled trials reporting 1 or more outcomes related to functional postoperative recovery. Study quality was assessed using a validated scale. DATA EXTRACTION Time to the first passage of flatus, time to first bowel movement, and length of postoperative stay. DATA SYNTHESIS Five trials (158 patients) satisfied the inclusion criteria. Time (in days) for the patient to pass flatus (weighted mean difference [WMD], − 0.66; 95% confidence interval [CI], − 1.11 to − 0.20; P = .005) and the time until the first bowel movement (WMD, − 1.10; 95% CI, − 1.79 to − 0.42; P = .002) were significantly reduced in the chewing gum group compared with controls. However, both of these results demonstrated significant heterogeneity. Postoperative length of stay was also reduced in the chewing gum group by longer than 1 day (WMD, − 1.25; 95% CI, − 3.27 to 0.77; P = .23); however, this result was not statistically significant. This result was significant when studies that explicitly included patients with stomas being formed during the surgery were excluded (WMD, − 2.46; 95% CI, − 3.14 to − 1.79; P &lt; .001), with no significant heterogeneity. CONCLUSIONS Chewing gum may enhance intestinal recovery following colectomy and reduce the length of hospital stay. Owing to the potential for substantial cost savings, larger-scale, blinded, randomized controlled trials with placebo arms are warranted.Arch Surg. 2008;143(8):788-793--

OBJECTIVE To evaluate postoperative adverse events and functional outcomes of patients undergoing restorative proctocolectomy with or without proximal diversion. DATA SOURCES The literature was searched by means of MEDLINE, Embase, Ovid, and Cochrane databases for all studies published from 1978 through July 15, 2005. STUDY SELECTION Comparative (randomized and nonrandomized) studies evaluating outcomes after restorative proctocolectomy with or without ileostomy were included. DATA EXTRACTION Three authors independently extracted data by using operative variables, early and late adverse events, and functional outcomes between the 2 groups. Trials were assessed by means of the modified Newcastle-Ottawa Score. Random-effects meta-analytical techniques were used for analysis. DATA SYNTHESIS The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). There were no significant differences in functional outcomes between the 2 groups. The development of pouch-related leak was significantly higher in the no-ileostomy group (odds ratio, 2.37; P = .002). Small-bowel obstruction was more common in the stoma group but was not statistically significant (odds ratio, 0.65). The development of anastomotic stricture favored the no-stoma group (odds ratio, 0.31; P = .045). On sensitivity analysis, pelvic sepsis was significantly less common in patients whose ileostomies were defunctioned; however, this finding was not mirrored by a significant difference in ileal pouch failure in this subgroup. CONCLUSIONS Restorative proctocolectomy without a diverting ileostomy resulted in functional outcomes similar to those of surgery with proximal diversion but was associated with an increased risk of anastomotic leak. Diverting ileostomy should be omitted in carefully selected patients only.Arch surg. 2008;143(4):406-412--