Search

An estimated 25% of patients with colorectal cancer (CRC) present with distant metastases at the time of diagnosis, the most common site being the liver. Controversy exists regarding the safety of a simultaneous versus staged approach to resections in these patients, but reports have shown that minimally invasive surgery (MIS) approaches can mitigate morbidity. This is the first study utilizing a large national database to investigate colorectal and hepatic procedure-specific risks in robotic simultaneous resections for CRC and colorectal liver metastases (CRLM). Utilizing the ACS-NSQIP targeted colectomy, proctectomy, and hepatectomy files, 1,550 patients were identified who underwent simultaneous resections of CRC and CRLM from 2016–2020. Of these patients, 311 (20%) underwent resections by an MIS approach, defined as an either laparoscopic (n = 241, 78%) or robotic (n = 70, 23%). Patients who underwent robotic resections had lower rates of ileus compared to those who had an open surgery. The robotic group had similar rates of 30-day anastomotic leak, bile leak, hepatic failure, and post operative invasive hepatic procedures compared to both the open and laparoscopic groups. The rate of conversion to open was significantly lower for robotic compared to laparoscopic group (9% vs. 22%, p = 0.012). This report is the largest study to date of robotic simultaneous CRC and CRLM resections reported in the literature and supports the safety and potential benefits of this approach.

Rectal cancer treatment is often multimodal, comprising of surgery, chemotherapy, and radiotherapy. However, the impact of coordination between these modalities is currently unknown. We aimed to assess whether delivery of nonsurgical therapy within same facility as surgery impacts survival in patients with rectal cancer.A patient cohort with rectal cancer stages II to IV who received multimodal treatment between 2004 and 2016 from National Cancer Database was retrospectively analyzed. Patients were categorized into three groups: (A) surgery + chemotherapy + radiotherapy at same facility (surgery + 2); (B) surgery + chemotherapy or radiotherapy at same facility (surgery + 1); or (C) only surgery at reporting facility (chemotherapy + radiotherapy elsewhere; surgery + 0). The primary outcome was 5-year overall survival (OS), analyzed using Kaplan-Meier curves, log-rank tests, and Cox proportional-hazards models.A total of 44,716 patients (16,985 [37.98%] surgery + 2, 12,317 [27.54%] surgery + 1, and 15,414 [34.47%] surgery + 0) were included. In univariate analysis, we observed that surgery+2 patients had significantly greater 5-year OS compared to surgery + 1 or surgery + 0 patients (5-year OS: 63.46% vs 62.50% vs 61.41%, respectively; P= .002). We observed similar results in multivariable Cox proportional-hazards analysis, with surgery + 0 group demonstrating increased hazard of mortality when compared to surgery + 2 group (HR: 1.09; P.001). These results held true after stratification by stage for stage II (HR 1.10; P= .022) and stage III (HR 1.12; P.001) but not for stage IV (P= .474).Greater degree of care coordination within the same facility is associated with greater OS in patients with stage II to III rectal cancer. This finding illustrates the importance of interdisciplinary collaboration in multimodal rectal cancer therapy.

Key Points Question Did the rates of avoidable complications and hospital costs among surgical patients change after the implementation of Maryland’s all-payer model, which caps hospital expenditures and mandates reductions in avoidable complications? Findings In this comparative effectiveness study of 525 262 Maryland patients who received surgery before and after implementation of Maryland’s all-payer model, lower complication rates were observed for coronary artery bypass grafting (11% decrease), carotid endarterectomy (2% decrease), hip arthroplasty (1% decrease), knee arthroplasty (, Importance In 2014, Maryland implemented the all-payer model, a distinct hospital funding policy that applied caps on annual hospital expenditures and mandated reductions in avoidable complications. Expansion of this model to other states is currently being considered; therefore, it is important to evaluate whether Maryland’s all-payer model is achieving the desired goals among surgical patients, who are an at-risk population for most potentially preventable complications. Objective To examine the association between the implementation of Maryland’s all-payer model and the incidence of avoidable complications and resource use among adult surgical patients. Design, Setting, and Participants This comparative effectiveness study used hospital discharge records from the Healthcare Cost and Utilization Project state inpatient databases to conduct a difference-in-differences analysis comparing the incidence of avoidable complications and the intensity of health resource use before and after implementation of the all-payer model in Maryland. The analytical sample included 2 983 411 adult patients who received coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), spinal fusion, hip or knee arthroplasty, hysterectomy, or cesarean delivery between January 1, 2008, and December 31, 2016, at acute care hospitals in Maryland (intervention state) and New York, New Jersey, and Rhode Island (control states). Data analysis was conducted from July 2019 to July 2021. Exposures All-payer model. Main Outcomes and Measures Complications (infectious, cardiovascular, respiratory, kidney, coagulation, and wound) and health resource use (ie, hospital charges). Results Of 2 983 411 total patients in the analytical sample, 525 262 patients were from Maryland and 2 458 149 were from control states. Across Maryland and the control states, there were statistically significant but not clinically relevant differences in the preintervention period with regard to patient age (mean [SD], 49.7 [19.0] years vs 48.9 [19.3] years, respectively; P, This comparative effectiveness study uses state inpatient data from the Healthcare Cost and Utilization Project to examine the association between the implementation of Maryland’s all-payer model and the incidence of avoidable complications and resource use among adult surgical patients.

OBJECTIVE: The purpose of this study was to evaluate the impact of optimization of preoperative comorbidities by nonsurgical clinicians on short-term postoperative outcomes. SUMMARY BACKGROUND DATA: Preoperative comorbidities can have substantial effects on operative risk and outcomes. The modifiability of these comorbidity-associated surgical risks remains poorly understood. METHODS: We identified patients with a major comorbidity (eg, diabetes, heart failure) undergoing an elective colectomy in a multipayer national administrative database (2010–2014). Patients were included if they could be matched to a preoperative surgical clinic visit within 90 days of an operative intervention by the same surgeon. The explanatory variable of interest (“preoperative optimization”) was defined by whether the patient was seen by an appropriate nonsurgical clinician between surgical consultation and subsequent surgery. We assessed the impact of an optimization visit on postoperative complications with use of propensity score matching and multilevel, multivariable logistic regression. RESULTS: We identified 4531 colectomy patients with a major potentially modifiable comorbidity (propensity weighted and matched effective sample size: 6037). After matching, the group without an optimization visit had a higher rate of complications (34.6% versus 29.7%, P = 0.001). An optimization visit conferred a 31% reduction in the odds of a complication (P < 0.001) in an adjusted analysis. Median preoperative costs increased by $684 (P < 0.001) in the optimized group, and a complication increased total costs of care by $14,724 (P < 0.001). CONCLUSIONS AND RELEVANCE: We demonstrated an association between use of nonsurgical clinician visits by comorbid patients prior to surgery and a significantly lower rate of complications. These findings support the prospective study of preoperative optimization as a potential mechanism for improving postoperative outcomes.

Objectives Early discontinuation of infliximab (IFX) in pregnant women with inflammatory bowel disease (IBD) decreases the intrauterine fetal exposure to the drug but may increase the risk of disease flaring leading to poor pregnancy outcomes. In this study, we assessed the impact of early IFX discontinuation on mother’s disease activity and on their at-risk babies. Methods In a retrospective study of the Truven Health Analytics MarketScan database from 2011 to 2015, we compared IBD patients who discontinued IFX more than 90 days (“early IFX”) with those who discontinue IFX 90 days or less (“late IFX) before delivery. We evaluated the risk of flaring, defined by new steroid prescriptions, visits to emergency room and/or hospital admissions, the pregnancy outcomes, and the at-risk babies. Results After IFX discontinuation, the early IFX group (68 deliveries) required significantly more steroid prescriptions than the late IFX group (318 deliveries) to control disease activity (P < 001). There were more preterm babies in the early IFX group (P < 049), but no difference within the 2 groups was noticed in the rate of intrauterine growth retardation, small for gestation, and stillborn babies. Similarly, there was no increase in acute respiratory infections, development delays, and congenital malformations in babies of the mothers from the late IFX vs early IFX groups. Conclusions Steroid-free remission IBD mothers are at risk for disease flares and preterm babies when IFX is discontinued early in pregnancy. Continuation of IFX seems to be safe at least for the first year of life.

Background: Anal cancer incidence is increasing in the US. Though formally established national anal cancer screening guidelines are nonexistent, many providers advocate screening to avoid late disease presentation. This study assesses the knowledge, attitudes, and practices of anal cancer screening among providers to identify the degree of variation and barriers to screening. Methods: Healthcare providers from two academic medical centers and a statewide community primary care group were surveyed using a questionnaire adapted from the National Survey of Primary Care Physicians’ Recommendations and Practice for Cancer Screening. Descriptive statistics were performed to explore providers’ responses and Fisher’s exact test to explore variation. Results: 86 providers completed the questionnaire (response rate 24.2%): 81.4% physicians, 18.6% advanced practitioners. 48.2% of respondents perform anal cancer screening. 5.8% correctly identified all high-risk patient factors. “HIV+ patient” was identified most frequently as high-risk (93.5%), “organ transplant recipient” (42.9%) least frequently. Anal pap test was the most recommended first-line screening test (76.6%) followed by digital anorectal exam (19.2%), HPV test (8.5%), and high-resolution anoscopy (HRA) (6.4%). Clinical evidence (72.3%) and national guidelines (70.2%) were most influential in guiding providers’ screening recommendations. Lack of qualified screening providers (34.1%), lack of patient follow-up after positive test results (22.7%), and patient non-compliance to initial screening (15.9%) were identified as “usual” barriers. Conclusions: Anal cancer screening attitudes and practices vary among providers. Development of national practice guidelines that define a multidisciplinary team approach from primary care anal cancer screening to specialist referral for HRA may reduce screening variability.

Background Certain behavioral traits and inadequate social support are known risk factors for complications after cancer surgery. Despite their importance, it is unclear whether conventional patient preoperative evaluation captures them. This study was conducted to assess concordance between documentation and patient survey of selected risk factors and to determine whether failure to document affected postoperative outcomes. Methods Adult patients at a tertiary academic medical center were surveyed before abdominal cancer surgery to assess 6 psychosocial risk factors. Risk factors were also assessed by retrospective chart review and compared with survey results through concordance measures. Thirty-day postoperative complications were abstracted by chart review. Rates of major complications for those with and without clinically missed risk factors were compared. Results Comparisons between chart review and screening survey revealed poor-to-moderate positive agreement (0%–47%) for 5 risk factors and strong negative agreement (82%–99%) among all risk factors. Kappa analysis demonstrated poor-to-fair agreement among 5 risk factors (κ = 0.112–0.423). The overall complication rate was 36%. The complication rate for patients with at least 1 clinically missed risk factor was 49% vs 24% in those without (P = .021), with a similar effect replicated for each individual risk factor. Conclusion This study shows a high level of discordance between formal screening and routine clinician documentation in a preoperative setting for psychosocial risk factors. There is a significant association between missing these risk factors and worse postoperative outcomes. Future work should examine whether structured screening of psychosocial risk factors may improve preoperative risk stratification through proactive interventions.

Increasing evidence supports immediate colectomy in acute fulminant ulcerative colitis in comparison with ongoing medical management. Prior studies have been limited to inpatient-only administrative data sets or single-institution experiences.The purpose of this study was to compare outcomes of early versus delayed emergency colectomy in patients admitted with ulcerative colitis flares while controlling for known preoperative risks and acuity.This is a cohort study of patients undergoing emergent total abdominal colectomies for ulcerative colitis compared by the timing of surgery.Adult patients undergoing an emergent total abdominal colectomy for ulcerative colitis, 2005 to 2015, were identified in the American College of Surgeons National Surgical Quality Improvement Program database.Patients undergoing total abdominal colectomy with an operative indication of ulcerative colitis admitted on a nonelective basis were selected.The primary outcomes measured were 30-day National Surgical Quality Improvement Program-reported mortality and postoperative complications, and early operation within 2 days of admission.We identified 573 total abdominal colectomies after propensity score matching. Median time to surgery was 1 hospital day in the early group versus 6 hospital days in the delayed group (p0.001). Early operation was associated with a lower mortality rate (4.9% versus 20.3% in matched groups, p0.001) and lower complication rate (64.5% versus 72.0%, p = 0.052). Multivariable logistic regression with propensity weighting of mortality on preoperative risk factors demonstrated that early surgery is associated with an 82% decrease in the odds of death compared with delayed surgery (p0.001). Regression of morbidity on preoperative risk factors demonstrated that early surgery is associated with a 35% decrease in the odds of a complication with delayed surgery (p = 0.034).Quality improvement data were used for clinical research questions.Patients undergoing immediate surgical intervention for acute ulcerative colitis have decreased postoperative complications and mortality rates. Rapid and early transitioning from medical to surgical management may benefit those expected to require surgery on the same admission. See Video Abstract at http://links.lww.com/DCR/A800.

Purpose There has been a noted reluctance to offer laparoscopic surgery to Crohn’s Disease patients due to the potential risks, and high rate, of converting the procedure to open. The purpose of this study was to compare clinical outcomes between Crohn’s Disease patients undergoing a planned open colectomy, to those undergoing a laparoscopic colectomy that was converted to open. Methods Crohn’s Disease patients undergoing an elective colectomy were identified using the ACS-NSQIP database (2012–2019). Patients were stratified based on operative approach: open, laparoscopic, and laparoscopic converted to open. Multivariable logistic regression was used to assess the impact of conversion to open on overall and serious postoperative morbidity. Results Among 8039 elective colectomies, 40.5% were performed open, 46.9% were completed laparoscopically, and 12.6% were converted to open. The conversion rate among all laparoscopic cases was 21.3%. On unadjusted analysis, conversion to open demonstrated similar rates of overall morbidity (P = 0.355) and serious morbidity (P = 0.724) compared to a planned open approach. On multivariable analysis, conversion to open was not associated with increased odds of overall morbidity (OR 1.12, 95% CI 0.94–1.30, P = 0.238) or serious morbidity (OR 1.20, 95% CI 0.98–1.46, P = 0.074), when compared to an open approach. Conclusion Among Crohn’s Disease patients, cases converted from laparoscopic to open exhibited similar outcomes as a planned open approach. Despite the limitations associated with this retrospective study, our findings suggest that laparoscopic surgery may be safely pursued among Crohn’s Disease patients, as the risks of conversion are potentially balanced by the benefits of laparoscopic surgery.

AIM Depression is a prevalent disorder that is associated with adverse health outcomes, but an understanding of its effect in colorectal surgery remains limited. The purpose of this study was to examine the impact of history of depression among patients undergoing colectomy. METHOD United States patients from Marketscan (2010-2017) who underwent colectomy were included and stratified by whether they had a history of depression within the past year, defined as (1) a diagnosis of depression during the index admission, (2) a diagnosis of depression during any inpatient or (3) outpatient admission within the year, and/or (4) a pharmacy claim for an antidepressant within the year. The primary outcomes were length of stay (LOS) and inpatient hospital charge. Secondary outcomes included in-hospital mortality and postoperative complications. Logistic, negative binomial, and quantile regressions were performed. RESULTS Among 88 981 patients, 21 878 (24.6%) had a history of depression. Compared to those without, patients with a history of depression had significantly longer LOS (IRR = 1.06, 95% CI [1.05, 1.07]), increased inpatient charge (β = 467, 95% CI [167, 767]), and increased odds of in-hospital mortality (OR = 1.37, 95% CI [1.08, 1.73]) after adjustment. History of depression was also independently associated with increased odds of respiratory complication, pneumonia, and delirium (all P

Background Depression has been linked to increased morbidity and mortality in patients after surgery. The purpose of this study is to investigate the impact of documented depression diagnosis on in-hospital postoperative outcomes of patients undergoing colorectal surgery. Materials and methods Patients from the National Inpatient Sample (2002-2017) who underwent proctectomies and colectomies were included. The outcomes measured included total hospital charge, length of stay, delirium, wound infection, urinary tract infection (UTI), pneumonia, deep vein thrombosis, pulmonary embolism, mortality, paralytic ileus, leak, and discharge trends. Multivariable logistic and Poisson regression analyses were performed. Results Of the 4,212,125 patients, depression diagnosis was present in 6.72% of patients who underwent colectomy and 6.54% of patients who underwent proctectomy. Regardless of procedure type, patients with depression had higher total hospital charges and greater rates of delirium, wound infection, UTI, leak, and nonroutine discharge, with no difference in length of stay. On adjusted analysis, patients with a depression diagnosis who underwent colectomies had increased risk of delirium (odds ratio (OR) 2.11, 95% confidence interval (CI) 1.93-2.32), wound infection (OR 1.08, 95% CI 1.03-1.12), UTI (OR 1.15, 95% CI 1.10-1.20), paralytic ileus (OR 1.06, 95% CI 1.03-1.09), and leak (OR 1.37, 95% CI 1.30-1.43). Patients who underwent proctectomy showed similar results, with the addition of significantly increased total hospital charges among the depression group. Depression diagnosis was independently associated with lower risk of in-hospital mortality (colectomy OR 0.58, 95% CI 0.53-0.62; proctectomy OR 0.72, 95% CI 0.55-0.94). Conclusions Patients with a diagnosis of depression suffer worse in-hospital outcomes but experience lower risk of in-hospital mortality after undergoing colorectal surgery. Further studies are needed to validate and fully understand the driving factors behind this.

Highlights • COVID-19 disrupted healthcare provision worldwide. • This is a four-phase multi-centre service evaluation of colorectal cancer services. • Conducted through a research collaborative in the UK, Ireland and the USA. • The aim is to evaluate the impact of the COVID-19 pandemic on service provision., Introduction COVID-19 has had an impact on the provision of colorectal cancer care. The aim of the CRC COVID study is to describe the changes in colorectal cancer services in the UK and USA in response to the pandemic and to understand the long-term impact. Methods and analysis This study comprises 4 phases. Phase 1 is a survey of colorectal units that aims to evaluate adherences and deviations from the best practice guidelines during the COVID-19 pandemic. Phase 2 is a monthly prospective data collection of service provision that aims to determine the impact of the service modifications on the long-term cancer specific outcomes compared to the national standards. Phase 3 aims to predict costs attributable to the modifications of the CRC services and additional resources required to treat patients whose treatment has been affected by the pandemic. Phase 4 aims to compare the impact of COVID-19 on the NHS and USA model of healthcare in terms of service provision and cost, and to propose a standardised model of delivering colorectal cancer services for future outbreaks. Ethics and dissemination This study is a service evaluation and does not require HRA Approval or Ethical Approval in the UK. Local service evaluation registration is required for each participating centre. In the USA, Ethical Approval was granted by the Research and Development Committee. The results of this study will be disseminated to stakeholders, submitted for peer review publications, conference presentations and circulated via social media. Registration details Nil.

Background In inflammatory bowel disease (IBD), many scenarios call for fecal diversion, leaving behind defunctionalized bowel. The theoretical risk of colorectal cancer (CRC) in this segment is frequently cited as a reason for resection. To date, no studies have characterized the incidence of neoplasia in the diverted colorectal segments of IBD patients. Methods A retrospective cohort analysis was conducted for IBD patients identified through a tertiary care center pathology database. Patients that had undergone colorectal diversion and were diverted for ≥ 1 year were included. Incidence of diverted dysplasia/CRC was calculated for Crohn’s disease (CD) and ulcerative colitis (UC) with respect to diverted patient-years (dpy) and patient-years of disease (pyd). Results In total, 154 patients comprising 754 dpy and 1984 pyd were analyzed. Only 2 cases of diverted colorectal dysplasia (CD 1, UC 1) and 1 case of diverted CRC (UC) were observed. In the UC cohort (n = 75), the rate of diversion-associated CRC was 4.5 cases/1000 dpy (95% CI 0.11–25/1000) or 1.5 cases/1000 pyd (95% CI 0.04–8.2/1000). In the CD cohort (n = 79), no patients developed CRC, although a dysplasia rate of 1.9 cases/1000 dpy (95% CI 0.05–11/1000) or 0.77 cases/1000 pyd (95% CI 0.02–4.3/1000) was observed. All patients developing neoplasia had disease duration > 10 years and microscopic inflammation. Conclusions Diverted dysplasia occurred infrequently with rates overlapping those reported in registries for IBD-based rectal cancers. Neoplasia was undetected in patients with < 10 pyd, regardless of diversion duration, suggesting low yield for endoscopic surveillance before this time.

Adherence to care processes and surgical outcomes varies by population subgroups for the same procedure. Enhanced recovery after surgery pathways are intended to standardize care, but their effect on process adherence and outcomes for population subgroups is unknown.This study aims to demonstrate the association between recovery pathway implementation, process measures, and short-term surgical outcomes by population subgroup.This study is a pre- and post-quality improvement implementation cohort study.This study was conducted at a tertiary academic medical center.A modified colorectal enhanced recovery after surgery pathway was implemented.Patients were included who had elective colon and rectal resections before (2013) and following (2014-2016) recovery pathway implementation.Thirty-day outcomes by race and socioeconomic status were analyzed using a difference-in-difference approach with correlation to process adherence.We identified 639 cases (199 preimplementation, 440 postimplementation). In these cases, 75.2% of the patients were white, and 91.7% had a high socioeconomic status. Groups were similar in terms of other preoperative characteristics. Following pathway implementation, median lengths of stay improved in all subgroups (-1.0 days overall, p ≤ 0.001), but with no statistical difference by race or socioeconomic status (p = 0.89 and p = 0.29). Complication rates in both racial and socioeconomic groups were no different (26.4% vs 28.8%, p = 0.73; 27.3% vs 25.0%, p = 0.86) and remained unchanged with implementation (p = 0.93, p = 0.84). By race, overall adherence was 31.7% in white patients and 26.5% in nonwhite patients (p = 0.32). Although stratification by socioeconomic status demonstrated decreased overall adherence in the low-status group (31.8% vs 17.1%, p = 0.05), white patients were more likely to have regional pain therapy (57.1% vs 44.1%, p = 0.02) with a similar trend seen with socioeconomic status.Data were collected primarily for quality improvement purposes.Differences in outcomes by race and socioeconomic status did not arise following implementation of an enhanced recovery pathway. Differences in process measures by population subgroups highlight differences in care that require further investigation. See Video Abstract at http://links.lww.com/DCR/A386.

BACKGROUND: The incidence of squamous cell carcinoma (SCC) of the anal canal has been rising over the past decades, especially in patients infected with human immunodeficiency virus (HIV). Despite the advent of potent multidrug regimens to treat HIV-termed highly active antiretroviral therapy (HAART), anal SCC rates have not declined, and the impact of HAART on anal SCC remains controversial. AIM: The purpose of this study was to define outcomes of anal SCC treatment in HIV-positive and HIV-negative patients. METHODS AND MATERIALS: A retrospective single-institution analysis was performed on all patients with anal SCC treated at the Johns Hopkins Hospital between 1991 and 2010. The primary outcomes measured were 5-year overall survival (5-year OS), median survival, and relapse rates. RESULTS: Our search identified 93 patients with anal SCC. Patients had a mean age of 54 years; 37.6% were male, and 21.5% were HIV-positive. Median follow-up was 28 months. Relapse occurred in 16.1% of patients. Median time to relapse was 20 months. Relapse rates were slightly higher with HIV-positive versus negative patients (30.0 vs.12.3%) but did not reach statistical significance (p = 0.06). Among HIV-positive patients, those who relapsed were more likely to be on HAART than those who did not relapse (83.3 vs. 14.3%, p = 0.007). 5-year OS was 58.9% for the total group of patients with no significant difference between those who relapsed versus those who did not (76.2 vs. 54.5%, p = 0.20). No survival difference was seen between HIV-positive and negative patients. Survival was associated with AJCC stage in all patients. CONCLUSION: In our small series, HIV infection was not associated with a significantly higher relapse rate or worse 5-year OS among patients with anal SCC. HAART was associated with a higher rate of relapse in HIV-positive patients. AJCC staging predicted survival in both relapsed and non-relapsed patients regardless of HIV status.

Timing of surgical intervention for acute ulcerative colitis has not been fully examined during the modern immunotherapy era. Although early surgical intervention is recommended, historical consensus for "early" ranges widely. The purpose of this study was to evaluate outcomes according to timing of urgent surgery for acute ulcerative colitis.All non-elective total colectomies in ulcerative colitis patients were identified in the National Inpatient Sample from 2002 to 2014. Procedures, comorbidities, diagnoses, and in-hospital outcomes were collected using International Classification of Disease, 9th Revision codes. An operation was defined as early if within 24 hours of admission. Results were compared between the early versus delayed surgery groups.We found 69,936 patients that were admitted with ulcerative colitis, and 2650 patients that underwent non-elective total colectomy (3.8%). Early intervention was performed in 20.4% of patients who went to surgery. More early operations were performed laparoscopically (28.1% versus 23.3%, p = 0.021) and on more comorbid patients (Charlson Index, p = 0.008). Median total hospitalization costs were $20,948 with an early operation versus $33,666 with a delayed operation (p 0.001). Delayed operation was an independent risk for a complication (OR = 1.46, p = 0.001). Increased hospitalization costs in the delayed surgery group were statistically significantly higher with a reported complication (OR = 3.00, p 0.001) and lengths of stay (OR = 1.26, p 0.001).Delayed operations for acute ulcerative colitis are associated with increased postoperative complications, increased lengths of stay, and increased hospital costs. Further prospective studies could demonstrate that this association leads to improved outcomes with immediate surgical intervention for medically refractory ulcerative colitis.

It is evident that the use of laparoscopy in the management of rectal cancer has gained popularity in the last few years. It is still, however, not widely accepted as the standard of care. Multiple randomized trials have shown that short-term outcomes and perioperative morbidity and mortality of laparoscopic proctectomy are equivalent to open surgery. However, data regarding long-term oncologic outcomes are still scarce, with only a few randomized trials reporting similar outcomes in both laparoscopic and open group. A more recent trial failed to replicate those results in patients with locally advanced rectal cancer. In this article, we will look at the most recent evidence regarding the use of laparoscopy for patients with rectal cancer. We will also briefly discuss the different approaches and new minimally invasive techniques used in this field, and we will talk about the challenges facing the widespread adoption of laparoscopic surgery in the management of rectal cancer.

Background There is continued debate regarding the optimal combinations of radiation therapy and chemotherapy in the preoperative treatment of locally advanced rectal adenocarcinomas. We report our single-institution experience of feasibility and early oncologic outcomes of short-course preoperative radiation therapy (5 Gy X 5 fractions) followed by consolidation neoadjuvant chemotherapy. Methods We reviewed the records of 26 patients with locally advanced rectal adenocarcinoma. All patients underwent short course radiotherapy (5 Gy X 5 fractions) followed by chemotherapy [either modified infusional and bolus 5-fluorouracail and oxalipatin (mFOLFOX6) or capecitabine and oxaliplatin] prior to consideration for surgery. A full course of chemotherapy was defined as at least 8 weeks of chemotherapy. Results There were five clinical (c) T2, 16 cT3, and five cT4 rectal tumors, with 88% cN+. Twenty-five patients received a median of 4 cycles (range 3 to 8) of mFOLFOX6 (with one cycle defined as a two-week period); one patient received 3 cycles of capecitabine and oxaliplatin. All patients completed SCRT; 81% completed the full course of neoadjuvant chemotherapy with 19% requiring dose reductions in chemotherapy, most commonly due to neuropathy. Nineteen patients underwent post-treatment endoscopic evaluation, and nine patients were noted to achieve a complete clinical response (CCR). Six of the nine patients who achieved CCR opted for a non-operative approach of watch-and-wait. Twenty patients underwent surgical resection; pathologic complete response was observed in seven (35%) of these twenty. The main radiation-associated toxicity was proctitis with CTCAE Grade 2 proctitis observed in seven patients (27%). Post-operative Clavien-Dindo Grade 3 complications within 30 days of surgery were identified in six patients (30%), with no Grade 4 or 5 adverse events. Median length of hospital stay was 4.5 days (range 2–16 days); three patients were readmitted within a 30 day period. Conclusions Short course preoperative radiotherapy followed by neoadjuvant chemotherapy was well-tolerated and achieved oncologic outcomes that compare favorably with short-course radiation therapy alone or long-course chemoradiotherapy. This regimen is associated with high rates of clinical and pathologic complete response.

Background All-cause readmission rates in patients undergoing ileostomy formation are as high as 20% to 30%. Dehydration is a leading cause. No predictive model for dehydration readmission has been described. Objective The purpose of this study was to develop and validate the Dehydration Readmission After Ileostomy Prediction scoring system to predict the risk of readmission for dehydration after ileostomy formation. Design Patients who underwent ileostomy formation were identified using the American College of Surgeons National Surgical Quality Improvement Program data set (2012-2015). Predictors for dehydration were identified using multivariable logistic regression analysis and translated into a point scoring system based on corresponding β-coefficients using 2012-2014 data (derivation). Model discrimination was assessed with receiver operating characteristic curves using 2015 data (validation). Settings This study used the American College of Surgeons National Surgical Quality Improvement Program. Patients A total of 8064 (derivation) and 3467 patients (validation) were included from the American College of Surgeons National Surgical Quality Improvement Program. Main outcome measures Dehydration readmission within 30 days of operation was measured. Results A total of 8064 patients were in the derivation sample, with 2.9% (20.1% overall) readmitted for dehydration. Twenty-five variables were queried, and 7 predictors were identified with points assigned: ASA class III (4 points), female sex (5 points), IPAA (4 points), age ≥65 years (5 points), shortened length of stay (5 points), ASA class I to II with IBD (7 points), and hypertension (9 points). A 39-point, 5-tier risk category scoring system was developed. The model performed well in derivation (area under curve = 0.71) and validation samples (area under curve = 0.74) and passed the Hosmer-Lemeshow goodness-of-fit test. Limitations Limitations of this study pertained to those of the American College of Surgeons National Surgical Quality Improvement Program, including a lack of generalizability, lack of ileostomy-specific variables, and inability to capture multiple readmission International Classification of Diseases, 9/10 edition, codes. Conclusions The Dehydration Readmission After Ileostomy Prediction score is a validated scoring system that identifies patients at risk for dehydration readmission after ileostomy formation. It is a specific approach to optimize patient factors, implement interventions, and prevent readmissions. See Video Abstract at http://links.lww.com/DCR/A746.

BACKGROUND: The specific effect of psychosocial risk factors on surgical outcomes in cancer patients remains unexplored. The purpose of this prospective observational study was to assess the association of preoperative psychosocial risk factors and 30-day complications following cancer surgery. METHODS: Psychosocial risks amongst elective gastrointestinal cancer surgery patients were ascertained through structured interviews using well-established screening forms. We then collected post-operative course by chart review. Multivariable analysis of short-term surgical outcomes was performed in those with a low versus a high number of psychosocial risks. RESULTS: 142 patients had a median age of 65 (interquartile range: 55-71) and were 55.9% male and 23.1% non-white. More than half (58.2%) of the study population underwent a resection for a hepato-pancreato-biliary primary tumor, and 31.9% had a colorectal primary tumor. High-risk biomedical comorbidities were present in 43.5% of patients. Three-quarters of patients (73.4%) had at least one psychosocial risk. Complication rates in patients with at least one psychosocial risk were 28.0 absolute percentage points higher than those with no psychosocial risks (54.4% versus 26.2%, p=0.039). Multiple psychosocial risk factors in medically comorbid patients independently conferred an increase in the odds of a complication by 3.37 times (OR 95% CI: 1.08-10.48, p=0.036) compared to those who had one or no psychosocial risks. CONCLUSIONS: We demonstrated a greater than three times odds of a complication in medically comorbid patients with multiple psychosocial risks. These findings support the use of psychosocial risks in preoperative assessment and consideration for inclusion in preoperative optimization efforts.

Background Accurate risk assessment before surgery is complex and hampered by behavioral factors. Underutilized risk-based decision-support tools may counteract these barriers. The purpose of this study was to identify perceptions of and barriers to the use of surgical risk-assessment tools and assess the importance of data framing as a barrier to adoption in surgical trainees. Methods We distributed a survey and risk assessment activity to surgical trainees at four training institutions. The primary outcomes of this study were descriptive risk assessment practices currently performed by residents, identifiable influences and obstacles to adoption, and the variability of preference sets when comparing modified System Usability Scores of a current risk calculator to a purpose-built calculator revision. Risk calculator comparison responses were compared with simple and multivariable regression to identify predictors for preferentiality. Results We collected responses from 124 surgical residents (39% response rate). Participants endorsed familiarity with direct verbal communication (100%), sketch diagrams (87%), and brochures (59%). The most contemporary risk communication frameworks, such as best-worst case scenario framing (38%), case-specific risk calculators (43%), and all-procedure calculators (52%) were the least familiar. Usage favored traditional models of communication with only 26% of residents regularly using a strategy other than direct verbal discussion or anatomic sketch diagrams. Barriers limiting routine use included lack of electronic and clinical workflow integration. The mean modified System Usability Scores domain scores were widely dispersed for all domains, and no domain demonstrated one calculator's superiority over another. Conclusion Risk assessment tools are underutilized by trainees. Of importance, preference sets of clinicians appear to be unpredictable and may benefit more from a customizable, bespoke approach.

Background: High dose-rate Intra-Operative Radiation Therapy (HD-IORT) is used to provide effective local control for patients with high-risk locally advanced or recurrent tumors. However, the utility of HD-IORT for patients with bladder cancer has not been studied. Objective: To characterize our institutional experience with HD-IORT in patients with cancer requiring genitourinary surgery, in an effort to identify patients with bladder cancer that may benefit from HD-IORT. Methods: We performed a retrospective review of all patients who have undergone HD-IORT during genitourinary surgery at our institution. Patients were stratified by surgical margin status, and primary outcomes assessed were overall survival, recurrence free survival and 90-day complications. Patients undergoing cystectomy and HD-IORT with sarcomatoid urothelial cancer were compared to a similar cohort undergoing cystectomy alone. A sample case of one such patient is discussed in detail. Results: 84 patients at our institution have undergone HD-IORT with genitourinary surgery. Positive surgical margin status was the greatest predictor of both OS (HR = 3.42) and RFS (HR = 2.61). The overall 90-day complication rate was 61%, with wound infections (43%) and GI complications (21%) being most common. 4 of these patients had sarcomatoid urothelial histology, and all are still alive with >2 yrs follow up. This compares to a 52% 1 yr survival in our sarcomatoid urothelial cohort (25 pts) that did not undergo HD-IORT. Conclusions: Our institutional experience with HD-IORT has been promising, particularly among patients with locally advanced disease and sarcomatoid histology. We are currently enrolling patients in a multi-institutional registry to assess the utility of HD-IORT in high risk bladder cancer.

High-dose-rate intraoperative radiation therapy (HDR-IORT) has historically provided effective local control (LC) for patients with unresectable and recurrent tumors. However, IORT is limited to only a few specialized institutions and it can be difficult to initiate an HDR-IORT program. Herein, we provide a brief overview on how to initiate and implement an HDR-IORT program for a selected group of patients with gastrointestinal and pelvic solid tumors using a multidisciplinary approach. Proper administration of HDR-IORT requires institutional support and a joint effort among physics staff, oncologists, surgeons, anesthesiologists, and nurses. In order to determine the true efficacy of IORT for various malignancies, collaboration among institutions with established IORT programs is needed.

BACKGROUND: We sought to identify differences among black and white Medicare-insured patients with colorectal cancer who underwent resection. METHODS: Surveillance, Epidemiology and End Results–Medicare (SEER-Medicare) linked inpatient data from 1986 to 2005 were examined. Differences in short- and long-term outcomes among black vs white patients were investigated. RESULTS: There were 125,676 (92.4%) white and 9,891 (7.6%) black patients who met the criteria. Black patients were younger (75.5 vs 77.2 years; P ,.001) but had more comorbidities than did white patients (mean Charlson comorbidity index score 3.99 vs 3.87; P ,.001). Black patients demonstrated greater odds of in-hospital mortality (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.30 to 1.56) and readmission within 30 days (OR, 1.26; 95% CI, 1.18 to 1.34). Comparing 1986 to 1990 vs 2001 to 2005, black patients had greater odds of 30-day readmission (OR, 1.12 vs 1.31) but reduced odds of index in-hospital mortality (OR, 1.84 vs 1.28). Black patients had worse long-term survival after colorectal surgery (hazard ratio [HR], 1.21; 95% CI, 1.17 to 1.25; P , .001). CONCLUSIONS: Black patients with colorectal cancer demonstrated increased risk of mortality and readmission after controlling for age, sex, and comorbidities. Although black vs white differences in perioperative mortality decreased over time, disparities in readmission and long-term survival persisted.

It is unclear whether intensive surveillance protocols have resulted in a decreased incidence of colorectal cancer (CRC) in inflammatory bowel disease (IBD). To determine the prevalence and characteristics of IBD associated high-grade dysplasia (HGD) or CRC that was undetected on prior colonoscopy. This is a single-center, retrospective study from 1994 to 2013. All participants had a confirmed IBD diagnosis and underwent a colectomy with either HGD or CRC found in the colectomy specimen.The undetected group had no HGD or CRC on prior colonoscopies. The detected group had HGD or CRC identified on previous biopsies. Of 70 participants, with ulcerative colitis (UC) (n = 47), Crohn’s disease (CD) (n = 21), and indeterminate colitis (n = 2), 29% (n = 20) had undetected HGD/CRC at colectomy (15 HGD and 5 CRC). In the undetected group, 75% had prior LGD, 15% had indefinite dysplasia, and 10% had no dysplasia (HGD was found in colonic strictures). Patients in the undetected group were more likely to have pancolitis (55 vs. 20%) and multifocal dysplasia (35 vs. 8%). The undetected group was less likely to have CRC at colectomy (25 vs. 62%). There was a trend toward right-sided HGD/CRC at colectomy (40 vs. 20%; p = 0.08). In addition, 84% of the lesions found in the rectum at colectomy were not seen on prior colonoscopy in the undetected group. The prevalence of previously undetected HGD/CRC in IBD found at colectomy was 29%. The high proportion of undetected rectal and right-sided HGD/CRC suggests that these areas may need greater attention during surveillance.

Existing studies that examine the effect of neoadjuvant chemoradiation (CRT) for locally advanced rectal cancer on patient quality of life (QOL) are limited. Our goals were to prospectively explore acute changes in patient-reported QOL endpoints during and after treatment and to establish a distribution of scores that could be used for comparison as new treatment modalities emerge.Fifty patients with locally advanced rectal cancer were prospectively enrolled at 2 institutions. Validated cancer-specific European Organization for Research and Treatment of Cancer (EORTC QLQ-CR30) and colorectal cancer-specific (EORTC QLQ-CR38 and EORTC QLQ-CR 29) QOL questionnaires were administered to patients 1 month before they began CRT, at week 4 of CRT, and 1 month after they had finished CRT. The questionnaires included multiple symptom scales, functional domains, and a composite global QOL score. Additionally, a toxicity scale was completed by providers 1 month before the beginning of CRT, weekly during treatment, and 1 month after the end of CRT.Global QOL showed a statistically significant and borderline clinically significant decrease during CRT (-9.50, P=.0024) but returned to baseline 1 month after the end of treatment (-0.33, P=.9205). Symptoms during treatment were mostly gastrointestinal (nausea/vomiting +9.94, P.0001; and diarrhea +16.67, P=.0022), urinary (dysuria +13.33, P.0001; and frequency +11.82, P=.0006) or fatigue (+16.22, P.0001). These symptoms returned to baseline after therapy. However, sexual enjoyment (P=.0236) and sexual function (P=.0047) remained persistently diminished after therapy.Rectal cancer patients undergoing neoadjuvant CRT may experience a reduction in global QOL along with significant gastrointestinal and genitourinary symptoms during treatment. Moreover, provider-rated toxicity scales may not fully capture this decrease in patient-reported QOL. Although most symptoms are transient, impairment in sexual function may persist after the completion of therapy and merits further investigation.

Background The incidence of anal cancer in human immunodeficiency virus (HIV)-positive individuals is increasing, and how co-infection affects outcomes is not fully understood. This study sought to describe the current outcome disparities between anal cancer patients with and without HIV undergoing abdominoperineal resection (APR). Methods A retrospective review of all US patients diagnosed with anal squamous cell carcinoma, undergoing an APR, was performed. Cases were identified using a weighted derivative of the Healthcare Utilization Project’s National Inpatient Sample (2000–2011). Patients greater than 60 years old were excluded after finding a skewed population distribution between those with and without HIV infection. Multivariable logistic regression and generalized linear modeling analysis examined factors associated with postoperative outcomes and cost. Perioperative complications, in-hospital mortality, length of hospital stay, and hospital costs were compared for those undergoing APR with and without HIV infection. Results A total of 1725 patients diagnosed with anal squamous cell cancer undergoing APR were identified, of whom 308 (17.9 %) were HIV-positive. HIV-positive patients were younger than HIV-negative patients undergoing APR for anal cancer (median age 47 years old versus 51 years old, p

BACKGROUND Intraoperative radiotherapy (IORT) has advantages over external beam radiation therapy (EBRT). Few studies have described side effects associated with its addition. We evaluated our institution's experience with abdominopelvic IORT to assess safety by postoperative complication rates. METHODS Prospectively collected IRB-approved database of all patients receiving abdominopelvic IORT (via high dose rate brachytherapy) at Johns Hopkins Hospital between November 2006 and May 2014 was reviewed. Patients were discussed in multidisciplinary conferences. Those selected for IORT were patients for whom curative intent resection was planned for which IORT could improve margin-negative resection and optimize locoregional control. Perioperative complications were classified via Clavien-Dindo scale for postoperative surgical complications. RESULTS A total of 113 patients were evaluated. Most common diagnosis was sarcoma (50/113, 44%) followed by colorectal cancer (45/113, 40%), most of which were recurrent (84%). There were no perioperative deaths. A total of 57% of patients experienced a complication Grade II or higher: 24% (27/113) Grade II; 27% (30/113) Grade III; 7% (8/113) Grade IV. Wound complications were most common (38%), then gastrointestinal (25%). No radiotherapy variables were significantly associated with complications on uni/multi-variate analysis. CONCLUSIONS Our institution's experience with IORT demonstrated historically expected postoperative complication rates. IORT is safe, with acceptable perioperative morbidity.

Genitourinary structures are at risk of injury during colorectal surgery. The incidence of injury is low; however, the risk is higher in cases involving severe inflammatory or infectious processes, locally advanced or recurrent cancer, previous radiation, and reoperation. Consideration of the anatomical relationship between the genitourinary system, and the colon and rectum is crucial to avoid injuries. Intraoperative diagnostic techniques such as intravenous pyelogram (IVP), fluoroscopic cystogram, or retrograde urethrogram can aid in identifying suspected injuries. Early recognition and repair of injuries decrease the morbidity of an injury. Repair of injuries depends on the location and extent of the injury. Simple injuries may be repaired primarily, while complex injuries may require more advanced repairs such as a flap reconstruction.

OBJECTIVE. MRI is currently the imaging modality of choice for the detection, characterization, and staging of rectal cancer. A variety of examinations have been used for preoperative staging of rectal cancer, including digital rectal examination, endorectal (endoscopic) ultrasound, CT, and MRI. Endoscopic ultrasound is the imaging modality of choice for small and small superficial tumors. MRI is superior to CT for assessing invasion to adjacent organs and structures, especially low tumors that carry a high risk of recurrence. CONCLUSION. High-resolution MRI is an accurate and sensitive imaging method delineating tumoral margins, mesorectal involvement, nodes, and distant metastasis. In this article, we will review the utility of rectal MRI in local staging, preoperative evaluation, and surgical planning. MRI at 3 T can accurately delineate the mesorectal fascia involvement, which is one of the main decision points in planning treatment.

Laparoscopic surgery for rectal cancer is much more challenging than that for colon cancer because of the confined space within the pelvis. Further, because of the tumor's location in the pelvis, maintenance of resection margins is of greater concern. Nonrandomized studies by groups experienced in laparoscopic surgery have shown both that it produces short-term outcomes equivalent to those for open surgery and that it can be performed safely from an oncologic perspective. Nonsurgical complications appear to be fewer, but conversion to open surgery may become a real issue. This review summarizes these findings by addressing technical considerations, early outcomes, late outcomes, costs, and complications.

Over the past 15 years, a series of high profile events including the publication of the Institute of Medicine Reports, To Err is Human (1999), and Crossing the Quality Chasm (2001), along with the rapid adoption of quality-based regulatory requirements and payment models, as well as the increasingly educated consumer has brought the subject of quality and safety front and center at virtually every hospital across the USA. While there is no doubt that overall we deliver better and safer care today, there is still a great deal of variability (Wang Y, Eldridge N, Metersky ML, et al. N Engl J Med. 370(4):341–51, 2014). As such, and especially in surgery, we must continue to strive to be better. Ultimately, to achieve consistent excellence in healthcare delivery, a major overhaul is required. Hospitals need to prioritize the development of strong, focused leadership teams that are accountable to a governing board and support trans-disciplinary care delivered by an engaged and motivated frontline staff of physicians, nurses, and ancillary providers. While this may appear to be an overwhelming task, and there is no doubt that the healthcare delivery in the USA will look markedly different in 10 years, the goal of this chapter is to highlight key areas in the field of quality and safety that are relevant to the practicing colorectal surgeon today.

Summary: The current study showed that short four day course endoluminal brachytherapy is an effective neoadjuvant treatment for locally advanced rectal cancer; however, it was associated with worsening post-treatment global quality of life and more gastrointestinal symptoms following treatment.Purpose: An attractive alternative to long course neoadjuvant chemoradiation (CRT) for rectal adenocarcinoma is short four day course endoluminal brachytherapy (EBT). However, quality of life (QOL) following EBT is unknown. We aim to compare post-treatment QOL between EBT and CRT.Methods: 17 patients with localized rectal cancer were prospectively enrolled on a pilot study of EBT. For comparison, prospectively collected QOL for 50 patients received CRT for rectal adenocarcinoma was included. QOL was measured using European Organization for Research and Treatment of Cancer (EORTC QLQ-C30 and EORTC QLQ-CR29) given to patients prior to, during, and at 3 – 6 weeks following treatment.Results: Comparing baseline mean scores to 3 – 6 weeks following EBT treatment, patients at the end of EBT had lower means scores in global functioning (81.0 vs. 53.0, p < 0.01); role functioning (90.0 vs. 63.0, p < 0.01); social functioning (91.0 vs. 68.0, p < 0.01); increased anxiety (89.0 vs. 62.0, p < 0.01); higher scores for pain (11.0 vs. 46.9, p < 0.01); fatigue (19.3 vs. 46.2, p < 0.01); and buttock pain (17.0 vs. 62.0, p < 0.01). Compared to mean difference of scores from baseline to the end of treatment for the control group, patients undergoing EBT had worsening global functioning (28.0 vs. 0, p < 0.01); physical functioning (12.2 vs. 2.0, p < 0.01); role functioning (27.1 vs. 3.3, p < 0.01); social functioning (23.4 vs. 1.0, p < 0.01); changes in weight (28.3 vs. 1.0, p < 0.01); higher scores for pain (35.8 vs. 6.7, p < 0.01); fatigue (26.9 vs. 1.2, p < 0.01); dysuria (17.9 vs. 5.3, p < 0.01); abdominal pain (27.2 vs. 2.8, p < 0.01); and buttock pain (45.6 vs. 8.0, p < 0.01).Conclusion: Although EBT is an effective alternative, rectal cancer patients may experience worse acute preoperative global QOL and more gastrointestinal symptoms following treatment. Efforts should be made to minimize these symptoms during treatment. Further studies are needed to determine the long-term effects of EBT on QOL.

Patients with Crohn's disease often present to the surgeon for operative intervention in poor overall condition. They may be taking multiple immunomodulators to attempt to manage their disease, may have significant weight loss and evidence of malnutrition, and 10 to 30% of the time will have intraabdominal sepsis in the form of an abscess or fistula. Preoperative optimization of these patients, when possible, may decrease morbidity and mortality, and may avoid formation of stomas for fecal diversion. Enhancing nutritional status and streamlining immunomodulator therapy prior to surgery may improve outcomes. Medical management of intraabdominal sepsis with percutaneous drainage of abdominal or pelvic abscesses may decrease postoperative septic complications, and may even avert the need for surgical intervention altogether.

Importance High-resolution anoscopy (HRA) is becoming increasingly advocated as a method of screening for anal dysplasia in high-risk patients. Objective To describe, through HRA findings, the association between patient symptomatology and anal dysplasia among patients at high risk for anal dysplasia. Design, Setting, and Participants Univariable and multivariable analyses were conducted of data from a prospectively maintained HRA database on all patients undergoing HRA with biopsy from November 1, 2011, to March 13, 2014, at a tertiary care HRA clinic. Data included demographics, medical history and comorbidities, HIV status and related measures (CD4 cell counts, HIV viral load, and use of highly active antiretroviral therapy), sexual orientation (when available), patient symptoms at initial presentation, physical examination findings, anal Papanicolaou (Pap) smear findings. Main Outcomes and Measures High-resolution anoscopy diagnosis of high- vs low-grade dysplasia or no dysplasia. Results One hundred sixty-one HRA biopsy specimens (mean [SEM], 1.77 [0.11] biopsy specimens per patient) were obtained from 91 patients (mean [SEM] age, 45.7 [1.2] years; 61 men [67%]; 47 black patients [52%]; and 70 human immunodeficiency virus–positive patients [77%]). Twenty-seven patients (30%) had high-grade dysplasia, 26 had low-grade dysplasia (29%), and 38 had no dysplasia (42%). The majority of patients (63 [69%]) were asymptomatic (anal pain, 11 [12%]; bleeding, 14 [15%]; and pruritus, 10 [11%]). Forty-one patients (45%) presented with anal pain (odds ratio, 5.25; 95% CI, 1.44-21.82;P = .02), and patients with either high- or low-grade dysplasia were more likely to present with anal lesions on physical examination compared with patients without dysplasia (odds ratio, 4.34; 95% CI, 1.78-11.20;P = .002). Multivariable analysis suggested that anal pain was independently associated with high-grade dysplasia (odds ratio, 6.42; 95% CI, 1.18-43.3;P = .03). Conclusions and Relevance Anal dysplasia is a silent disease that is frequently asymptomatic. However, patients with anal pain, anal lesions, and other high-risk factors are at increased risk of having high-grade anal dysplasia. These patients may benefit from routine screening with HRA.

Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects. The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0–10 were interpreted as success whereas scores of 11–20 indicated failure. A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3–131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups. A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.