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Postoperative day (POD) 1 laboratory tests are routinely ordered after bariatric operations. Determine how often these laboratory tests are abnormal and whether they represent value-added care. Academic medical center, United States. Patients undergoing bariatric operations for obesity and complications from prior bariatric surgery from 1 January 2011 to 12 December 2020 at a single institution were identified. Patients with POD 1 hemoglobin, potassium, creatinine, or glucose serum laboratory tests obtained before 08:00 on POD 1 were reviewed. Laboratory-specific exclusion criteria were applied. Abnormal laboratory test results were a hemoglobin < 8.0 g/dL or a hemoglobin drop of > 3.0 g/dL; a potassium < 3.5 mmol/L (hypokalemia), 5.5–5.9 mmol/L (mild hyperkalemia), or ≥ 6.0 mmol/L (severe hyperkalemia); a creatinine increase of 0.3 g/dL or 1.5X the preoperative value (acute kidney injury); and a glucose > 180 mg/dL (hyperglycemia). Intervention for abnormal hemoglobin, potassium, and glucose was also assessed. Of 2090 patients who underwent bariatric operations, 1969 met inclusion criteria for hemoglobin analysis, 1223 for potassium analysis, 1446 for creatinine analysis, and 563 for glucose analysis. Only 0.2% (n = 4) of patients had a hemoglobin < 8.0 g/dL< and only 3.1% (n = 62) had a > 3.0 g/dL hemoglobin drop. Potassium was abnormal in 2.8% of patients (n = 34 total). An acute kidney injury was diagnosed in 1.8% (n = 26) of patients. Hyperglycemia was identified in 2.1% (n = 12) of patients. Of 5227 laboratory test values, only 1.5% were abnormal. Further, of laboratory tests analyzed for intervention (n = 3781), only 14 (0.4%) were actively acted upon. Routine POD 1 laboratory tests after bariatric operations seem to be a continuation of a surgical tradition rather than a clinically valuable tool. POD 1 laboratory tests should be ordered based on specific patient co-morbidities and clinical criteria. [Display omitted] [ABSTRACT FROM AUTHOR]

Minimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease. A retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group). Among the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P =.004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P =.002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P =.463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P =.463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P =.231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P =.309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P =.188). Minimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results. [ABSTRACT FROM AUTHOR]

Avoiding unnecessary inpatient stay may decrease hospital-acquired complications and costs while increasing patient satisfaction. This study aimed to develop and validate a score to identify patients eligible for safe same-day discharge after colorectal resections. This bi-institutional retrospective cohort study included consecutive patients undergoing elective colon and rectal resections (2011–2018) for benign and malignant indications. Two multivariable logistic models were developed based on demographic and surgical risk factors to predict a combined endpoint (ileus, anastomotic leak, intra-abdominal abscess, and readmission). Development and validation datasets were randomly sampled from the entire cohort. Areas under the receiver operating characteristic curves (AUC) were evaluated, and Hosmer-Lemeshow goodness-of-fit tests were used to assess validation model fit. Of 5,389 patients, 1,182 (21.9%) experienced at least one complication of the combined endpoint. Male gender, open surgery, ASA ≥3, wound class ≥3, ileostomy, surgical duration >3 hours, and perioperative IV fluids >3 L all had significantly greater odds of the combined endpoint in the parsimonious multivariable model (all P <.05). The reduced model considering only the 4 variables with the highest OR (>1.5) contained open surgery, ASA ≥3, wound class ≥3, and surgical duration ≥3 hours as predictors (all P <.05, AUC of 0.65; 95% CI 0.63, 0.68). Both the parsimonious model and the reduced model demonstrated no lack of fit in the validation cohort. The suggested score composed of preand intraoperative items may help physicians decide on patients' same-day discharge after colorectal resection. [ABSTRACT FROM AUTHOR]

There is limited data about the safety of colorectal surgery after immune checkpoint inhibitors (ICI). We aimed to share our experience about postoperative outcomes of colorectal surgery for patients treated with ICI. Overall, 31 patients were identified, 22 (71%) underwent elective and nine (29%) underwent emergent/urgent surgery. The 30-day Clavien Dindo class ≥ III complication rates were 27.3% (n = 6) for elective and 55.5% (n = 5) for emergent/urgent cases. Four patients underwent emergency surgery for immune-related colonic perforation and developed postoperative septic shock; two died. Considering patients' comorbidities, cancer stage, and surgical complexity, elective colorectal surgery after ICI seems relatively safe. However, emergent/urgent colorectal surgery was associated with high postoperative morbidity. Indeed, colonic perforation in the setting of ICI treatment has a significant risk of postoperative mortality. Therefore, for patients on ICI with any acute abdominal symptoms, surgical consult should be involved, and colon perforation should be ruled out. [ABSTRACT FROM AUTHOR]

Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery. This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019. Pretreatment magnetic resonance imaging (MRI) reports were reviewed for all the patients. Risk factors for pathological CRM involvement were investigated using Firth's logistic regression and a predictive model based on preoperative radiological features was formulated. A total of 305 patients were included, and 14 (4.6%) had CRM involvement. Multivariable logistic regression found both T3 >5 mm (OR 6.12, CI 1.35–36.44) and threatened or involved mesorectal fascia (OR 4.54, CI 1.33–17.55) on baseline MRI to be preoperative predictors of pathologic CRM positivity, while anterior location (OR 3.44, CI 0.72–33.13) was significant only on univariate analysis. The predictive model showed good discrimination (area under the receiver-operating characteristic curve >0.80) and predicted a 32% risk of positive CRM if all risk factors were present. Patients with pre-operatively assessed threatened radiological margin, T3 tumors with greater than 5 mm extension and anterior location are at risk for a positive CRM. The predictive model can preoperatively estimate the CRM positivity risk for each patient, allowing surgeons to tailor management to improve oncological outcomes. [ABSTRACT FROM AUTHOR]

While minimally invasive surgery contributed to improved outcomes in bariatric surgery, less is known about current utilization trends and outcomes related to surgical technique for colorectal resections in super-obese patients (body mass index ≥50 kg/m2). The aim of this study was to compare surgical modalities and short-term outcomes of patients with super obesity who underwent elective colectomy in the United States. A retrospective review was performed of patients with super obesity who underwent elective colectomy between 2012 to 2018 using the American College of Surgeons National Quality Improvement Program data pool. Patients were categorized into an open, laparoscopic, or robotic group. Baseline characteristics and perioperative outcomes including 30-day complications and length of stay were compared between the 3 groups. Furthermore, utilization trends of surgical modalities were assessed. Of 1199 patients, 338 (28.2%) had open, 735 (61.3%) laparoscopic, and 126 (10.5%) robotic colectomy during the study period, primarily for colon cancer (50.8%). Patients in the open group tended to have more baseline co-morbidities. Laparoscopic approach showed better risk-adjusted outcomes compared with open for postoperative ileus (adjusted odds ratio [aOR]:.6, 95% confidence interval [CI;.383–.965]), overall medical complications (aOR:.4, 95%CI [.3–.8]), and length of stay (OR.6, 95% CI [.394–.968]). Trend utilization showed increasing utilization of the robotic platform over the study period, which was associated with less unplanned conversion to open (aOR.417, 95%CI [.199–.872]). Laparoscopic colectomy provides advantageous outcomes over open surgery for colectomy in super-obese patients. The robotic platform has been increasingly used over time, and potential benefits need to be further studied. [ABSTRACT FROM AUTHOR]

This study aimed to analyze fluid management standards in 2 high-volume, enhanced recovery after surgery institutions 7 years after implementation. Retrospective analysis of consecutive patients undergoing elective, segmental colonic and extensive colorectal resections for benign and malignant pathology (2011–2017). Administration and composition of intravenous fluids, postoperative weight gain, and factors impeding compliance to preidentified fluid thresholds (3L fluid administration, 2.5 kg weight gain) were assessed. Multivariable logistic regression was performed to identify risk factors for postoperative adverse events. A total of 5,155 patients were included. Among them, 2,320 patients (45.1%) received >3 L intravenous fluids at postoperative day 0. Fluid totals remained unchanged over the 7-year observation period. Fluid overload was independently associated with postoperative weight gain ≥2.5 kg at postoperative day 2 (odds ratio 1.34, P <.001). Patients with high American Society of Anesthesiologists score (≥3) undergoing open and longer (≥180 minutes) procedures were more likely to exceed both thresholds according to multivariable analysis (all P <.001). Other than open surgery, American Society of Anesthesiologists score ≥3, contamination class ≥3, and malignancy, both thresholds (≥3 L: odds ratio 1.76, 95% confidence interval 1.44–2.15, ≥ 2.5 kg: odds ratio 1.62, 95% confidence interval 1.33–1.97) were independent risk factors for postoperative adverse outcomes (occurring in 28.1% of patients). Compliance with fluid thresholds appears to be challenging in patients with comorbidities undergoing open and long procedures. Efforts are encouraged because both thresholds are linked to adverse outcomes and appear to be potentially modifiable in selected patients. [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]

To assess the impact of delay from diagnosis to curative surgery on survival in patients with non-metastatic colon cancer. National Cancer database (NCDB) analysis (2004–2013) including all consecutive patients diagnosed with stage I-III colon cancer and treated with primary elective curative surgery. Short and long delays were defined as lower and upper quartiles of time from diagnosis to treatment, respectively. Age-, sex-, race-, tumor stage and location-, adjuvant treatment-, comorbidity- and socioeconomic factors-adjusted overall survival (OS) was compared between the two groups (short vs. long delay). A multivariable Cox regression model was used to identify the independent impact of each factor on OS. Time to treatment was <16 days in the short delay group (31,171 patients) and ≥37 days in the long delay group (29,617 patients). OS was 75.4 vs. 71.9% at 5 years and 56.6 vs. 49.7% at 10 years in short and long delay groups, respectively (both p < 0.0001). Besides demographic (comorbidities, advanced age) and pathological factors (transverse and right-vs. left-sided location, advanced tumor stage, poor differentiation, positive microscopic margins), treatment delay had a significant impact on OS (HR 1.06, 95% CI 1.05–1.07 per 14 day-delay) upon multivariable analysis. The adjusted hazard ratio for death increased continuously with delay times of longer than 30 days, to become significant after a delay of 40 days. This analysis using a national cancer database revealed a significant impact on OS when surgeries for resectable colon cancer were delayed beyond 40 days from time of diagnosis. [ABSTRACT FROM AUTHOR]

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

Abstract Background There is limited consensus regarding risk factors for postoperative bleeding. The objective of this work was to investigate the capability of machine learning techniques in combination with practice-based longitudinal electronic medical record data for identifying potential new risk factors for postoperative bleeding and predicting patients at high risk of postoperative bleeding. Methods A retrospective study was conducted for patients who underwent colorectal surgery 1998–2015 at a single tertiary referral center. Various predictors were extracted from electronic medical record. The outcome of interest was the occurrence of postoperative bleeding within 7 days of surgery. Logistic regression and gradient boosting machine models were trained. Area under the receiver operating curve and area under the precision recall curve were used to evaluate the performance to different models. Results Of 13,399 cases undergoing colorectal resection, 1,680 (12.5%) experienced postoperative bleeding. A total of 299 variables were evaluated. Logistic regression and gradient boosting machine models returned an area under the receiver operating curve of 0.735 and 0.822 and area under the precision recall curve of 0.287 and 0.423, respectively. In addition to well-known risk factors for postoperative bleeding, nutrition (ranked third), weakness (ranked fifth), patient mobility (ranked sixth), and activity level (ranked eighth) were found to be novel predictors in the gradient boosting machine model based on permutation importance. Conclusion The study identified measures of functional capacity of patient as novel predictors of postoperative bleeding. The study found that risk of postoperative bleeding can be assessed, allowing for better use of human resources in addressing this important adverse event after surgery. [ABSTRACT FROM AUTHOR]

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

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

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

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

Background: There is a paucity of data pertaining to the natural history and outcomes of patients with well-differentiated rectal carcinoids. Objective: To correlate endoscopic size with the natural history and outcome. Design: Retrospective study. Setting: Single tertiary referral center. Patients: Eighty-seven patients with endoscopically identified well-differentiated rectal carcinoid tumors. Intervention: Colonoscopy. Main Outcome Measurements: Prevalence of metastasis at diagnosis, disease progression, and survival. Results: Metastasis was present at diagnosis in 3%, 66%, and 73% of tumors measuring ≤10 mm, 11 to 19 mm, and ≥20 mm, respectively. Metastasis was predicted with 100% sensitivity and 87% specificity using an endoscopic lesion size ≥9 mm. In patients without identified metastasis, 64% were identified during screening colonoscopy. Within this select cohort, subsequent metastasis was discovered only at distant extra pelvic sites, in 1.6%, 50%, and 100% of patients with tumors initially measuring ≤10 mm, 11 to 19 mm, and ≥20 mm, respectively. The carcinoid related 5- and 10-year survival rates for locally confined disease were 96%. The corresponding survival rates for local and advanced metastatic disease were 60% and 35%, respectively. Limitations: Subjective estimation of tumor size, mitotic index or Ki-67 labeling index not reported, and lack of formal and standardized baseline staging algorithm and surveillance program. Conclusions: The clinical behavior of 11- to 19-mm tumors appears to mimic that of larger (>20 mm) lesions with respect to the presence of metastasis at diagnosis and disease progression. Therefore, if local therapy is contemplated, we propose to make a distinction between ≤10-mm and 11- to 19-mm tumors, favoring an aggressive staging and management protocol for 11- to 19-mm carcinoid tumors. [Copyright &y& Elsevier]

Abstract: Purpose: To assess the toxicity and efficacy of intensity modulated radiation therapy (IMRT) combined with chemotherapy in treatment of anal cancer. Methods and Materials: We examined the records of 34 consecutive patients who received chemoradiation therapy with IMRT as initial treatment for squamous cell carcinoma of the anus between June 2005 and January 2009. The median radiation dose was 50.4 Gy (range, 48.6-57.6 Gy). Chemotherapy was given concurrently: 5-fluorouracil alone in 1 patient and combination 5-fluorouracil and mitomycin C in all others. Endpoints included local control and survival, as well as toxicity. Acute and late toxicity was scored with the Common Terminology Criteria for Adverse Events version 3.0. Results: Twenty-eight patients presented with T1 and T2 disease and 6 with T3 and T4 disease. Fourteen patients had regional nodal metastases. The median age was 59 years (range, 46-85 years). Median follow-up in surviving patients was 22 months. The estimated 2-year survival was 93% (95% confidence interval, 76%-98%). Three patients (9%) had local relapse (estimated 2-year local control, 90%; 95% confidence interval, 74%-97%). One patient had relapse in a regional node. Acute grade 3-4 hematologic toxicity was observed in 20 patients (59%). Other acute grade 3 or grade 4 toxicity included the gastrointestinal tract in 3 patients (9%) and skin in 5 patients (15%). Two patients (6%) had late grade 3 or grade 4 gastrointestinal tract toxicity. Conclusions: Treatment of anal squamous cell carcinoma with IMRT and chemotherapy is effective and has an acceptable toxicity profile. [Copyright &y& Elsevier]

Background & Aims: It is not clear whether medical therapy, surgery, or both is the best approach for patients with Crohn''s disease who develop an intra-abdominal abscess. Methods: We evaluated data from patients with Crohn''s disease who were diagnosed with a radiologically confirmed abdominal abscess (enhancing fluid collection, ≥1 cm) from 1999 to 2006 (n = 95; median age, 42.0 y; 50.5% female). Medical/nonsurgical methods (percutaneous aspiration ± drain placement) were used for 55 patients (mean abscess size, 6.9 ± 3.2 cm), and 40 patients underwent surgical interventions (laparotomy ± bowel resection; mean abscess size, 7.5 ± 3.7 cm). We investigated risk factors for abscess recurrence. Results: The median length of hospitalization was 15.5 days for patients who underwent surgery and 5.0 days for patients who did not (P < .001). The 5-year cumulative probability of abscess recurrence was 31.2% among patients who did not undergo surgery and 20.3% among those who did (P = .25). Histories of perianal or active ileal disease predicted abscess recurrence. Initiation of pharmacologic therapy after drainage reduced the risk for abscess recurrence (P < .001). Anti–tumor necrosis factor therapy, compared with no therapy, reduced the risk of abscess recurrence (P = .001) in all patients, whereas immunosuppressive monotherapy, compared with no therapy, had a trend toward significant risk reduction (P = .06). Conclusions: Among patients with Crohn''s disease who have intra-abdominal abscesses, nonsurgical and primary surgical management strategies result in similar rates of abscess recurrence and complications. Initiation of anti–tumor necrosis factor and/or immunosuppressive therapy when abscesses resolve might protect against intra-abdominal penetrating disease. [Copyright &y& Elsevier]

Background: The objectives were to determine the feasibility of combined rectal and hepatic resections and analyze the disease-free survival and overall survival.Study Design: Sixty patients who underwent resection for metastatic rectal disease from 1991 to 2005 at Mayo Clinic were reviewed. Inclusion criteria were: rectal cancer with metastatic liver disease and resectability of metastases. The exclusion criteria were: metachronous resection (n = 15). Kaplan-Meier Survival estimated overall survival (OS) and disease-free survival (DFS). Cox proportional hazard models examined the association between groups and survival.Results: The cohort comprised 22 men and 23 women, with median age of 63 years. Surgical management included: abdominoperineal resection, 13 patients (29%); low anterior resection, 29 (64%); local excision, one; total proctocolectomy, one; and pelvic exenteration, one. Major hepatic resection was performed in 22%. There was no mortality, but there were 26 postoperative complications. Disease-free survival from local recurrence at 1, 2, and 5 years was 92%, 86%, and 80%, respectively. Disease-free survival from distant recurrence at 1, 2, and 5 years was 62%, 43%, and 28%, respectively. Overall survival at 1, 2 and 5 years was 88%, 72%, and 32%, respectively.Conclusions: Combined rectal and hepatic resection is safe. Morbidity and mortality do not preclude concurrent resection. The DFS and OS are comparable to that of patients undergoing a staged procedure. [ABSTRACT FROM AUTHOR]

Background: There have been numerous studies with conflicting results regarding the use of anti-tumor necrosis factor (TNF) therapy and its relationship to postoperative outcome in Crohn disease. The aim of our study was to examine the rate of postoperative morbidity in patients receiving anti TNF therapy in the perioperative period.Methods: All patients undergoing surgery for Crohn disease from 2005 till 2008 were abstracted from a prospective database. Patients undergoing surgery which included a suture or staple line at risk for leaking were selected for the study. A retrospective review of medical records was performed. The study group comprised patients treated with perioperative anti TNF therapy (defined as treatment within 8 weeks preoperatively or up to 30 days postoperatively). The remainder of the patients did not receive perioperative anti TNF therapy. Patient characteristics, disease severity, medication use, operative intervention and 30-day complication were compared between the two groups.Results: Three hundred and seventy patients were selected for analysis in this study, of which 119 received perioperative anti TNF therapy and 251 did not. The groups were similar in baseline characteristics, perioperative risk factors and procedures. The group who received perioperative anti TNF therapy had a more severe disease overall as measured by the American College of Gastroenterology (ACG) categories of disease (50% severe fulminant disease in the perioperative anti-TNF therapy group versus 18% in the group that did not receive perioperative anti-TNF therapy, p < 0.001). There was no significant association of perioperative anti TNF therapy and any postoperative complications (27.9% in anti-TNF group versus 30.1% in no anti-TNF group, p = 0.63) nor intra-abdominal infectious complications (5.0% in anti-TNF group versus 7.2% in no anti-TNF group, p = 0.44). Univariate analysis showed that the only factors associated with an increase in postoperative intra-abdominal infections were age and penetrating disease.Conclusions: The use of anti-TNF therapy in the perioperative period is safe and is not associated with an increase in overall or infectious complications in Crohn disease patients undergoing surgery. [ABSTRACT FROM AUTHOR]

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

Background: Hand-assisted laparoscopic surgery (HALS) is an established alternative to laparoscopic-assisted surgery, but limited data exist regarding its applicability for colorectal cancer (CRC). We report short-term outcomes in a large series of CRC patients who underwent HALS between 2004 and 2009. Methods: A prospectively maintained database was used to identify all CRC patients. Patients with colon cancer (CC) and rectal cancer (RC) were considered separately. Three patients with synchronous CC and RC were excluded. Data are frequency (%) or median (interquartile range). Results: Between 2004 and 2009, 323 CRC patients underwent a HALS procedure. Median age was 65 (53–73) years, 39% were women, and the median BMI was 27 (24–31) kg/m2. Diagnoses included 194 colon cancers (CC, 56.7% stage I/II), 129 rectal cancers (RC, 62.7% stage I/II). Operative time was less for CC than RC (157 vs 204 min; P < .0001). Conversion to laparotomy occurred in similar proportions of CC and RC cases (14% vs 10%; P = .38); lymph nodes retrieval was also similar (18 vs 18; P = .45). Overall duration of stay was 5 (4–7) days. At 30 days, postoperative complications occurred in similar proportions of CC and RC patients (28% vs 30%; P = .72). There was 1 mortality (0.5%). For the subgroup with 3 year follow-up, (73 CC and 45 RC patients), the overall survival was 80% and 88% (CC and RC, respectively), and disease free survival 79% and 85%, respectively. Conclusion: Colon and rectal cancer can be resected safely using HALS techniques. Conversion rates are low, complication rates expected, durations of hospital stay shorter, and the number of lymph nodes retrieved is high. [Copyright &y& Elsevier]

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

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

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

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

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

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