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Background: Patients with anemia undergoing elective colorectal cancer surgery are known to have significantly higher rates of postoperative complications and worse outcomes., Objective: This study aimed to improve rates of anemia screening and treatment in patients undergoing elective colon and rectal resections through a quality improvement initiative., Design: We compared a historical cohort of patients before implementation of our anemia screening and treatment quality improvement program to a prospective cohort after implementation., Settings: This study was conducted at a tertiary care hospital., Patients: This study included all adult patients with a new diagnosis of colon or rectal cancer without evidence of metastatic disease between 2017 and 2019., Interventions: The interventions include the anemia screening and treatment quality improvement program., Main Outcome Measures: The primary outcome was hospital cost per admission., Results: This study includes a total of 84 patients who underwent elective colon or rectal resection before implementation of our anemia quality improvement project and 88 patients who underwent surgery after. In the preimplementation cohort 44 of 84 patients (55.9%) were anemic compared to 47 of 99 patients (54.7%) in the postimplementation cohort. Rates of screening (25%-86.4%) and treatment (27.8%- 63.8%) were significantly increased in the postimplementation cohort. Mean total cost per admission was significantly decreased in the postimplementation cohort (mean cost $16,827 vs $25,796; p = 0.004); this significant reduction was observed even after adjusting for relevant confounding factors (ratio of means: 0.74; 95% CI, 0.65-0.85). The mechanistic link between treatment of anemia and reductions in cost remains unknown. No significant difference was found in rates of blood transfusion, complications, or mortality between the groups., Limitations: The study limitation includes before-after design subjected to selection and temporal biases., Conclusions: We demonstrate the successful implementation of an anemia screening and treatment program. This program was associated with significantly reduced cost per admission. This work demonstrates possible value and benefits of implementation of an anemia screening and treatment program. See Video Abstract at http://links.lww.com/DCR/C15 .RESULTADOS DE LOS PACIENTES SOMETIDOS A RESECCIÓN INTESTINAL ELECTIVA ANTES Y DESPUÉS DE LA IMPLEMENTACIÓN DE UN PROGRAMA DE DETECCIÓN Y TRATAMIENTO DE ANEMIA., Antecedentes: Se sabe que los pacientes anémicos que se someten a una cirugía electiva de cáncer colorrectal tienen tasas significativamente más altas de complicaciones posoperatorias y peores resultados., Objetivo: Mejorar las tasas de detección y tratamiento de la anemia en pacientes sometidos a resecciones electivas de colon y recto a través de una iniciativa de mejora de calidad., Diseo: Comparamos una cohorte histórica de pacientes antes de la implementación de nuestro programa de detección de anemia y mejora de la calidad del tratamiento con una cohorte prospectiva después de la implementación., Entorno Clinico: Hospital de atención terciaria., Pacientes: Todos los pacientes adultos con un nuevo diagnóstico de cáncer de colon o recto sin evidencia de enfermedad metastásica entre 2017 y 2019., Intervenciones: Detección de anemia y programa de mejora de la calidad del tratamiento., Principales Medidas De Resultado: El resultado primario fue el costo hospitalario por ingreso., Resultados: Un total de 84 pacientes se sometieron a resección electiva de colon o recto antes de la implementación de nuestro proyecto de mejora de calidad de la anemia y 88 pacientes se sometieron a cirugía después. En la cohorte previa a la implementación, 44/84 (55,9 %) presentaban anemia en comparación con 47/99 (54,7 %) en la cohorte posterior a la implementación. Las tasas de detección (25 % a 86,4 %) y tratamiento (27,8 % a 63,8 %) aumentaron significativamente en la cohorte posterior a la implementación. El costo total medio por admisión se redujo significativamente en la cohorte posterior a la implementación (costo medio $16 827 vs. $25 796, p = 0,004); esta reducción significativa se observó incluso después de ajustar los factores de confusión relevantes (proporción de medias: 0,74, IC del 95 %: 0,65 a 0,85). El vínculo mecánico entre el tratamiento de la anemia y la reducción de costos sigue siendo desconocido. No hubo diferencias significativas en las tasas de transfusión de sangre, complicaciones o mortalidad entre los grupos., Limitaciones: El diseño de antes y después está sujeto a sesgos temporales y de selección., Conclusiones: Demostramos la implementación exitosa de un programa de detección y tratamiento de anemia. Este programa se asoció con un costo por admisión significativamente reducido. Este trabajo demuestra el valor y los beneficios posibles de la implementación de un programa de detección y tratamiento de la anemia. Consulte Video Resumen en http://links.lww.com/DCR/C15 . (Traducción- Dr. Francisco M. Abarca-Rendon )., (Copyright © The ASCRS 2022.)

Background: Ligation of the intersphincteric fistula tract is a sphincter-preserving technique for the treatment of anal fistulas. The BioLIFT modification involves the placement of a biologic mesh in the intersphincteric plane. Advocates of this modification state improved healing rates, however evidence for this is lacking, and this approach costs significantly more., Objective: The purpose of this study was to compare the healing rates of the ligation of the intersphincteric fistula tract with the BioLIFT., Design: This was a retrospective cohort study., Settings: The study was conducted at a tertiary care hospital from April 2008 to April 2018., Patients: All adult patients with transsphincteric anal fistulas were included. Patients were excluded if they had IBD, more than 1 fistula tract operated on simultaneously, or a previous attempt at repair., Main Outcome Measures: The primary outcome was primary healing of the fistula tract, and secondary outcomes included overall success, complications, and time to recurrence., Results: There were 119 cases (75 ligation of the intersphincteric fistula tract and 44 BioLIFTs). One surgeon performed 84% of the BioLIFT cases. The primary healing rate was 75.0% versus 58.7% (p = 0.08), and the complication rate was 22.7% versus 17.3% (p = 0.48; BioLIFT vs ligation of intersphincteric fistula tract). After multivariate logistic regression, the BioLIFT had a significantly better healing rate (OR = 2.38 (95% CI, 1.01-5.62); p = 0.048). Median follow-up was 9 versus 29 weeks (BioLIFT vs ligation of intersphincteric fistula tract). Kaplan-Meier analysis demonstrated no difference in the time to recurrence (p = 0.48)., Limitations: This study was limited by the retrospective nature, different lengths of follow-up, and varying case numbers between the surgeons., Conclusions: The BioLIFT modification is safe and effective for the treatment of anal fistulas but has a higher cost. This modification warrants additional prospective studies to establish its benefits over the ligation of the intersphincteric fistula tract procedure. See Video Abstract at http://links.lww.com/DCR/B139. COMPARACIÓN DE LIFT VERSUS BIOLIFT PARA EL TRATAMIENTO DE LA FÍSTULA ANAL TRANSFINTERÉRICA: UN ANÁLISIS RETROSPECTIVO: Ligadura del tracto de la fístula interesfintérica es una técnica para preservación del esfínter en el tratamiento de las fístulas anales. La modificación BioLIFT implica la colocación de una malla biológica en el plano interesfintérico. Protagonistas de la modificación mejoraron las tasas de curación, sin embargo, carecen evidencias definitivas y la técnica eleva costos significativamente.Comparar las tasas de curación de ligadura del tracto de la fístula interesfintérica con el BioLIFT.Estudio de cohorte retrospectivo.Hospital de atención de tercer nivel desde abril de 2008 hasta abril de 2018.Se incluyeron todos los pacientes adultos con fístulas anales transfinteréricas. Los pacientes fueron excluidos si tenían enfermedad inflamatoria intestinal, más de un tracto fistuloso operado simultáneamente o con un intento previo de reparación.El resultado principal fue la curación primaria del tracto fistuloso y los resultados secundarios incluyeron el éxito en general, las complicaciones y tiempo hasta recurrencia.Se registraron 119 casos (75 ligaduras del tracto de la fístula interesfintérica y 44 BioLIFT). Un cirujano realizó el 84% de los casos de BioLIFT. La tasa de curación primaria fue del 75.0% vs 58.7%, p = 0.08, y la tasa de complicaciones fue del 22.7% vs 17.3%, p = 0.48 comparando BioLIFT vs ligadura del tracto de la fístula interesfintérica. Después de la regresión logística multivariada, el BioLIFT tuvo una tasa de curación significativamente mejor (OR 2.38 [IC 95% 1.01-5.62], p = 0.048). La mediana de seguimiento fue de 9 vs 29 semanas (BioLIFT vs ligadura del tracto de la fístula interesfintérica). El análisis de Kaplan-Meier no demostró diferencias en el tiempo hasta la recurrencia (p = 0,48).Este estudio estuvo limitado por ser retrospectivo, las diferentes duraciones de seguimiento y el número variable de casos entre los cirujanos.La modificación BioLIFT es segura y efectiva para el tratamiento de las fístulas anales pero tiene un costo más alto. Esta modificación amerita más estudios prospectivos para establecer los beneficios sobre ligadura del tracto de la fístula interesfintérica. Consulte Video Resumen en hhttp://links.lww.com/DCR/B139.

Background: A large proportion of Canadians experience fecal incontinence, with no avenue for effective treatments. The Ottawa Hospital has recently started a percutaneous tibial nerve stimulation program for patients who have not improved with conservative efforts., Objective: As part of this program implementation, a qualitative needs assessment was undertaken to better define successful outcomes and to identify barriers for program sustainability., Design: This was a cross-sectional, qualitative study involving standardized, semistructured interviews., Settings: The study was conducted at a single tertiary care center., Patients: Patients experiencing fecal incontinence, as well as nurses, physical therapists, and physicians, were enrolled in the study., Main Outcome Measures: Interview questions revolved around success definitions, barriers, and promoters of fecal incontinence care. Transcripts were analyzed to develop themes surrounding fecal incontinence care., Results: Twelve interviews were undertaken raising a total of 17 different themes. Barriers to fecal incontinence care included education for both the care provider and patients. Access issues for treatments were also highlighted. Promoters of fecal incontinence care were reflected by the impact that it has on quality of life, personal hygiene, psychological burden, and activity and productivity. The definition of fecal incontinence success was focused on improvements in quality of life rather than a numerical reduction of incontinence episodes., Limitations: This study was limited in its small number of interviews conducted. We were unable to identify patients who were unable to seek out care for fecal incontinence., Conclusions: Patient and care provider education surrounding fecal incontinence is lacking. Furthermore, access for effective treatments is a real barrier for Canadians experiencing fecal incontinence. Programs should focus on improvement of overall quality of life rather than a reduction of incontinence episodes.

Background: In rectal cancer surgery, low anterior resection and abdominoperineal resection have equivocal impact on overall quality of life. A rectal cancer decision aid was developed to help patients weigh features of options and share their preference., Objective: The aim of this study was to evaluate the effect of a patient decision aid for mid to low rectal cancer surgery on the patients' choice and decision-making process., Design: A before-and-after study was conducted. Baseline data collection occurred after surgeon confirmation of eligibility at the first consultation. Patients used the patient decision aid at home (online and/or paper-based formats) and completed post questionnaires., Setting: This study was conducted at an academic hospital referral center., Patients: Adults who had rectal cancer at a maximum of 10 cm proximal to the anal verge and were amenable to surgical resection were considered. Those with preexisting stoma and those only receiving abdominoperineal resection for technical reasons were excluded from the study., Intervention: Patient with rectal cancer were provided with a decision aid., Main Outcome Measures: The primary outcomes measured were decisional conflict, knowledge, and preference for a surgical option., Results: Of 136 patients newly diagnosed with rectal cancer over 13 months, 44 (32.4%) were eligible, 36 (81.9%) of the eligible patients consented to participate, and 32 (88.9%) patients completed the study. The mean age of participants was 61.9 ± 9.7 years and tumor location was on average 7.3 ± 2.1 cm above the anal verge. Patients had poor baseline knowledge (52.5%), and their knowledge improved by 37.5% (p < 0.0001) after they used the patient decision aid. Decisional conflict was reduced by 24.2% (p = 0.0001). At baseline, no patients preferred a permanent stoma, and after decision aid exposure, 2 patients (7.1%) preferred permanent stoma. Over 96% of participants would recommend the patient decision aid to others., Limitations: This study was limited by the lack of control for potential confounders and potential response bias., Conclusions: The patient decision aid reduced decisional conflict and improved patient knowledge. Participants would recommend it to other patients with rectal cancer.

Background: Combined endoscopic-laparoscopic surgery is a novel technique that can be used to avoid bowel resection for complex colon polyps that are not amenable to colonoscopic resection., Objective: The aim of this study was to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery for complex colonic polyps., Design: This study is a retrospective review of consecutive combined endoscopic-laparoscopic surgeries., Setting: This study was conducted at a single institution., Patients: All patients that underwent combined endoscopic-laparoscopic surgery for a complex colonic polyp at our center from October 2009 to October 2013 were followed. Each patient's lesion was assessed by a therapeutic endoscopist before referral for combined endoscopic-laparoscopic surgery, and was deemed unresectable based on size, broad base, or location of the polyp., Main Outcome Measures: Intraoperative and postoperative complications, length of hospital stay, and recurrence were the primary outcomes measured., Results: Thirty consecutive patients underwent combined endoscopic-laparoscopic surgery. Twenty (66.7%) patients underwent laparoscopic-assisted colonoscopic polyp excision (10 of these excisions were facilitated by Endoloop placement at the polyp base), 9 (30%) patients underwent colonoscopic-assisted laparoscopic cecectomy, and 1 (3.3%) patient was converted from a colonoscopic-assisted laparoscopic cecectomy to a laparoscopic ileocolic resection. The median length of hospital stay was 2 days (range, 1-16). Twenty-nine (96.7%) of the final pathology results were benign, with 10 (33.3%) showing high-grade dysplasia. One (3.3%) final pathology result was positive for a well-differentiated adenocarcinoma. This patient subsequently underwent a laparoscopic right hemicolectomy and chemotherapy for node-positive disease. One (3.3%) patient experienced a recurrent benign polyp at the previous excision site, which was removed by colonoscopy. The time to detection of recurrence was 274 days., Limitations: This study looked at a small group of patients, over a short follow-up period. However, all consecutive patients were captured, and there were no losses to follow-up., Conclusions: Combined endoscopic-laparoscopic surgery for complex benign colonic polyps is a safe procedure, with good clinical outcomes and low recurrence rates.

Background: Previous research in colorectal cancer has focused on survival, recurrence, and functional outcomes. Few have assessed the decisional needs of patients or the information patients are retaining from the informed consent process., Objectives: The aims of this study were to describe the decisional needs of adult patients with rectal cancer when deciding on the surgical treatment of their disease and to identify gaps in patients' recollection of the informed consent discussion., Design: Face-to-face interviews were conducted with the use of a questionnaire based on the validated Ottawa Decision Support Framework Needs Assessment., Setting: This study was performed at a university-based academic Cancer Assessment Center, in Ottawa, Ontario, Canada., Patients: Adult patients with rectal cancer treated with low anterior resection or abdominoperineal resection were included., Main Outcome Measures: The primary outcomes measured were patients' knowledge and understanding of decision and their decisional needs., Results: Thirty patients were interviewed between November 2009 and July 2010. Eighty percent were male, with a median age of 65. None of the patients perceived having a choice of surgical options. When questioned about the main outcomes of rectal cancer surgery, 47% could not recall a preoperative discussion of risks to bowel function, 47% could not recall a preoperative discussion of risks to sexual function, and 57% could not recall a preoperative discussion of risks to urinary function. Patients would like information regarding functional outcomes, body image, and the immediate postoperative period. A minority of patients desire information regarding cure rate, need for a second surgery, or the ability of surgery to treat their symptoms. Patients would like information that is portable and trusted by their health care team that they can review at their own time., Limitations: To avoid introducing decisional conflict before surgery, patients were interviewed at the first postoperative visit. Preoperative informed consent discussions were not standardized., Conclusion: Despite a comprehensive educational oncology pathway, patients retain little of the informed consent discussion. This study highlights the dichotomy between the outcomes that surgeons and patients value most. The results of this study will guide future efforts to improve informed consent.

Introduction: The management of complex fistulas is difficult. Maintaining continence while achieving durable fistula closure is the goal of surgical management. This study describes our experience with a novel sphincter-sparing technique called the ligation of the intersphincteric fistula tract, which involves ligation and division of the fistula tract in the intersphincteric space., Methods: All patients from July 2007 to December 2008 with trans- or suprasphincteric fistula treated with the procedure were prospectively followed. Procedures were performed by surgeons with fellowship training in a referral center. Demographic data, comorbidities, previous repair attempts, and postoperative data were collected., Results: A total of 39 patients underwent a ligation of the intersphincteric fistula tract during a 17-month period. Median age was 49 years. A total of 29 patients (74%) had previous attempts at repair, with a median of 2 failed repairs. Follow-up data were available in 90% (35 of 39). Median follow-up was 20 weeks. Successful fistula closure was achieved in 57% of the patients (20 of 35). Median time to failure was 10 weeks (range, 2-38 weeks). No patient reported any subjective decrease in continence after the procedure., Conclusion: Ligation of the intersphincteric fistula tract is a new sphincter-sparing procedure for complex transsphincteric fistula. The success rate is comparable with other sphincter-preserving techniques. Importantly, it appeared to effectively preserve continence. Adding safe, muscle-sparing surgical options to our armamentarium for dealing with transsphincteric fistula is essential. Additionally, the procedure is easy to learn and has very low cost. Long-term follow-up and randomized, controlled trials are necessary to assess efficacy and durability.

Purpose: The purpose was to determine if the perioperative benefits associated with laparoscopic colectomies are maintained as operative time increases., Methods: A retrospective review was performed of a database that was prospectively collected from April 1991 to May 2005. Since operative time distributions were different, patients were divided into three groups: laparoscopic right colectomy or ileocecal resection, sigmoid resection, and total abdominal colectomy. The following outcomes were assessed: intraoperative and postoperative complications, days to surgical diet, length of stay, 30-day mortality, and the presence of a learning curve., Results: Following exclusions, there were 231 right colon and ileocecal resections, 210 sigmoid colectomies, and 46 total abdominal colectomies. With increasing operative time in both right/ileocecal and sigmoid resections, logistic regression demonstrated no significant association between intraoperative and postoperative complications, days to surgical diet, or length of stay. Weight was significantly correlated with increasing operative time in the right/ileocecal and sigmoid resection groups. In the total abdominal colectomy group, significant relationships between increased operative time and postoperative complications (P = 0.04), days to surgical diet (P = 0.02), and hospital stay (P = 0.03) were found. An operative time cut-point was determined in the total abdominal colectomy group. Patients with operative times >270 minutes were more likely to have postoperative complications (P = 0.024), longer ileus (five vs. three median days to surgical diet, P = 0.003), and longer length of stay (seven vs. five days, P = 0.04). This increased risk remained significant after adjusting for weight and diagnosis. No significant learning curve was identified., Conclusion: Increasing operative time does not appear to adversely affect perioperative outcomes in segmental colectomies. Total abdominal colectomies lasting more than 270 minutes were associated with increased postoperative complications, days to surgical diet, and length of stay.

Purpose: This study was designed to evaluate whether neoadjuvant therapy is a risk factor for anastomotic leakage after rectal cancer surgery., Methods: A retrospective review of 220 patients who underwent tumor-specific mesorectal excision for rectal cancer from 2000 to 2005 was performed. Risk factors for leak were identified by using a multivariable regression model., Results: A total of 54 patients received neoadjuvant chemoradiation therapy and surgery, whereas 166 received surgery alone. No difference in clinically significant leaks was observed between the two groups (5.6 vs. 6.6 percent, P = 1). A diverting ileostomy was performed in 26.4 percent of patients who received neoadjuvant therapy compared with 9.7 percent for surgery alone (P = 0.0021). Neoadjuvant patients were more likely to have ultralow anastomoses (17.6 vs. 2.5 percent, P < 0.0001). On multivariate analysis, smoking (odds ratio, 6.37 (1.8, 22.2), P = 0.004), difficult anastomosis (odds ratio, 7.66 (1.8, 31.5), P = 0.0048), and low level of anastomosis (

Purpose: This study was designed to assess whether the exclusion criteria used in the Clinical Outcomes of Surgical Therapy and Colon Cancer Laparoscopic or Open Resection trials affected the generalizability of their findings., Methods: A prospective database of consecutive laparoscopic resections performed for colon cancer was reviewed. Patients were categorized into two groups: inclusion group and exclusion group, based on the selection criteria used in the Clinical Outcomes of Surgical Therapy and Colon Cancer Laparoscopic or Open Resection trials. Baseline and perioperative data were analyzed by using t-tests, Wilcoxon's rank-sum, chi-squared, and Fisher's exact test. Kaplan-Meier survival curves, followed by adjustment for tumor nodes metastasis stage and age utilizing a Cox proportional hazard model, were performed., Results: The inclusion group had 221 patients and the exclusion group had 166 (median age and gender distribution were similar). The exclusion group had a higher conversion rate (23 vs. 11.3 percent; P=0.0023). There was no difference in intraoperative complications (9 percent for exclusion group vs. 8.6 percent for inclusion group; P=0.8), operative time (180 minutes for exclusion group vs.172 minutes for inclusion group; P=0.24), or postoperative complication rates (33.7 percent for exclusion group vs. 26 percent for inclusion group; P=0.13). No difference was detected in perioperative mortality rates, length of stay, days to diet as tolerated, and adjusted two-year survival., Conclusions: No differences were found in outcomes between the two groups in terms of operative/postoperative complications, length of stay, perioperative mortality, and two-year survival. It seems that all patients with colon cancer can potentially benefit from a laparoscopic approach.

Purpose: Issues surrounding the safety and efficacy of palliative laparoscopic resections for patients with Stage IV colorectal cancer have not been explicitly examined in the literature. This article describes our experience with laparoscopic procedures for patients with Stage IV colorectal cancer and compares their perioperative outcomes to a contemporaneous group of patients with clinically curable (Stages I-III) disease., Methods: A prospective database of laparoscopic resections for colorectal cancer performed between 1991 and 2002 was reviewed. Data regarding patient demographics, perioperative morbidity and mortality, operative times, conversion rates, and length of stay were extracted. Statistical analysis included chi-squared and Student's t-tests as required and P