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Clostridioides difficile infection occurs when the bacterium produces toxin that causes diarrhea and inflammation of the colon. These guidelines indicate the preferred approach to the management of adults with C. difficile infection and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation process. In instances where the evidence was not appropriate for Grading of Recommendations Assessment, Development, and Evaluation but there was consensus of significant clinical merit, key concept statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not the only, approach to clinical scenarios.

Laparoscopic proctocolectomy with ileal pouch-anal anastomosis is the removal of the entire colon and rectum with creation of an ileal neo-reservoir. It is performed for patients with inflammatory or neoplastic processes isolated to the colon and rectum with good sphincter control and without involvement of the small bowel or anus.

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen

Background Despite data suggesting safety and efficacy in ulcerative colitis patients treated with inpatient infliximab, prior studies did not focus on patients with extensive colitis, the group at highest risk for requiring surgery. Methods This was a single center, retrospective study (2008-2015) of consecutive patients who required admission because of severe extensive ulcerative colitis defined by preoperative symptoms and computed tomography scans and postoperative histology. Patients admitted for high-dose steroids were compared with steroid refractory inpatients provided with one or two infusions of infliximab. The primary study outcome was colectomy rates; secondary outcomes included mean length of stay and 60-d complication rates. Results A total of 174 patients required admission with steroids for extensive ulcerative colitis. Of these, 19 (10%) also received infliximab. Among the subjects treated with infliximab, 15 (78%) required total colectomy during that admission versus 81 (52%) who received steroids alone ( P = 0.03). Postoperative readmission rates, surgical-site infections, return to the operating room, and all-complication rates were similar between the cohorts ( P > 0.05). Conclusions For steroid refractory extensive ulcerative colitis, inpatient infliximab did not lower colectomy rates or increase postoperative complications compared with patients treated with steroids alone.

Squamous cell cancers of the anus are rare GI malignancies for which neoadjuvant chemoradiation is the first-line treatment for nonmetastatic disease. Squamous cancers of the rectum are far less common, and it is unclear to what degree chemoradiotherapy improves their outcomes.The purpose of this study was to compare stage-specific survival for anal and rectal squamous cancers stratified by treatment approach.This was a retrospective cohort study.The study was conducted at Commission on Cancer designated hospitals.Patients (2006-2012) identified in the National Cancer Database with pretreatment clinical stage I to III cancers who underwent chemoradiotherapy, with and without subsequent salvage surgical resection (low anterior resection or abdominoperineal resection), ≥12 weeks after chemoradiotherapy were included in the study.Overall survival and the need for salvage surgery were measured.Anal cancers (n = 11,224) typically presented with stage II (45.7%) or III (36.3%) disease, whereas rectal cancer stages (n = 1049) were more evenly distributed (p0.001). More patients with rectal cancer underwent low anterior or abdominoperineal resections 12 weeks or later after chemoradiotherapy versus those undergoing abdominoperineal resection for anal cancer (3.8% versus 1.2%; p0.001). Stage I and II rectal cancer was associated with poorer survival compared with anal cancer (stage I, p = 0.017; stage II, p0.001); survival was similar for stage III disease. Salvage surgery for anal cancer was associated with worse survival for stage I to III cancers; salvage surgery did not significantly affect survival for rectal cancer.This was a retrospective study without cancer-specific survival measures.Squamous rectal cancers are associated with significantly worse survival than squamous cancers of the anus for clinical stage I and II disease. Despite both cancers exhibiting squamous histology, rectal cancers may be less radiosensitive than anal cancers, as suggested by the greater incidence of salvage surgery that does not appear to significantly improve overall survival. See Video Abstract at http://links.lww.com/DCR/A422.

We studied whether risk factors for infectious complications differed between inpatient (IP) and postdischarge (PD) periods in patients undergoing colon surgery.Among partial colon resection patients in the National Surgical Quality Improvement Program (2005 to 2010), we identified risk factors for superficial and deep (D-SSI) surgical site infections and urinary tract infections in the IP and PD phases of care.Obesity was associated with higher risk of both IP superficial surgical site infections and D-SSI (odds ratio [OR] 1.41, P.0001 and OR 1.28, P.0001) and increasing to OR 1.73 (P.0001) and OR 1.83 (P.0001), respectively, in the PD period. Smoking was associated with development of D-SSI, and this risk increased from IP to PD phases of care (OR 1.15, P = .02 to OR 1.54, P.0001).Risk factors for infections differ between IP and PD phases of care in colon surgery patients. Earlier discharge from the hospital may shift recognition of an SSI to the outpatient setting.

Background The optimal treatment for an intra-abdominal abscess/infection secondary to perforating ileocolic Crohn's disease (PCD) is unclear. Methods Forty-seven consecutive PCD patients treated via an institutional protocol of ileocolectomy after a 7-day period of percutaneous abscess drainage were retrospectively compared with 160 consecutive patients who underwent an elective ileocolectomy for Crohn's disease (ECD) between 1992 and 2014. Outcomes were compared using univariate analysis and propensity score matching. Results Univariate analysis demonstrated significant differences in ileostomy rates (PCD: 48.9% vs ECD: 18.8%; P = .001), 30-day readmissions (PCD: 38.3% vs ECD: 18.8%; P = .01), and overall 30-day postoperative complications (PCD: 29.8% vs ECD: 15%; P = .03). After matching, a statistically significant difference was retained in ileostomy rates ( P = .02) and 30-day readmissions ( P = .01). Conclusions Early operative intervention after percutaneous drainage in perforating CD may be associated with a high incidence of diversions and readmissions.

C. difficile infection (CDI) has become more common as well as more severe. Antibiotics represent the most important, and the most potentially modifiable, risk factor. However, the widespread use of proton pump inhibitors may represent a significant risk factor for CDI in the general population. Knowledge of the most frequently used severity scoring systems may help the surgeon in selecting antibiotic therapy. The choice to surgically intervene requires a careful balance between timely care and providing adequate time for aggressive medical therapy to be effective. The role of colectomy versus the construction of a diverting ileostomy with colonic lavage requires further study. Fecal microbiota transplant (FMT) has much to commend it, even for the care of severe forms of CDI.

Clostridioides difficile infection (CDI) is a common healthcare- and antibiotic-associated diarrheal disease. If mis-diagnosed, or incompletely treated, CDI can have serious, indeed fatal, consequences. The clinical and economic burden imposed by CDI is great, and the US Centers for Disease Control and Prevention has named the causative agent, C. difficile (CD), as an Urgent Threat To US healthcare. CDI is also a significant problem in the agriculture industry. Currently, there are no FDA-approved preventives for this disease, and the only approved treatments for both human and veterinary CDI involve antibiotic use, which, ironically, is associated with disease relapse and the threat of burgeoning antibiotic resistance. Research efforts in multiple laboratories have demonstrated that non-toxin factors also play key roles in CDI, and that these are critical for disease. Specifically, key CD adhesins, as well as other surface-displayed factors have been shown to be major contributors to host cell attachment, and as such, represent attractive targets for anti-CD interventions. However, research on anti-virulence approaches has been more limited, primarily due to the lack of genetic tools, and an as-yet nascent (but increasingly growing) appreciation of immunological impacts on CDI. The focus of this review is the conceptualization and development of specific anti-virulence strategies to combat CDI. Multiple laboratories are focused on this effort, and the field is now at an exciting stage with numerous products in development. Herein, however, we focus only on select technologies (Figure 1) that have advanced near, or beyond, pre-clinical testing (not those that are currently in clinical trial), and discuss roadblocks associated with their development and implementation.

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. This Clinical Practice Guidelines Committee is charged with leading international effort

Importance Recent evidence from an animal model suggests that peripheral loss of eosinophils inClostridium difficileinfection (CDI) is associated with severe disease. The ability to identify high-risk patients with CDI as early as the time of admission could improve outcomes by guiding management decisions. Objective To construct a model using clinical indices readily available at the time of hospital admission, including peripheral eosinophil counts, to predict inpatient mortality in patients with CDI. Design, Setting, and Participants In a cohort study, a total of 2065 patients admitted for CDI through the emergency department of 2 tertiary referral centers from January 1, 2005, to December 31, 2015, formed a training and a validation cohort. The sample was stratified by admission eosinophil count (0.0 cells/μL or >0.0 cells/μL), and multivariable logistic regression was used to construct a predictive model for inpatient mortality as well as other disease-related outcomes. Main Outcomes and Measures Inpatient mortality was the primary outcome. Secondary outcomes included the need for a monitored care setting, need for vasopressors, and rates of inpatient colectomy. Results Of the 2065 patients in the study, 1092 (52.9%) were women and patients had a mean (SD) age of 63.4 (18.4) years. Those with an undetectable eosinophil count at admission had increased in-hospital mortality in both the training (odds ratio [OR], 2.01; 95% CI, 1.08-3.73;P = .03) and validation (OR, 2.26; 95% CI, 1.33-3.83;P = .002) cohorts in both univariable and multivariable analysis. Undetectable eosinophil counts were also associated with indicators of severe sepsis, such as admission to monitored care settings (OR, 1.40; 95% CI, 1.06-1.86), the need for vasopressors (OR, 2.08; 95% CI, 1.32-3.28), and emergency total colectomy (OR, 2.56; 95% CI, 1.12-5.87). Other significant predictors of mortality at admission included increasing comorbidity burden (for each 1-unit increase: OR, 1.13; 95% CI, 1.05-1.22) and lower systolic blood pressures (for each 1-mm Hg increase: OR, 0.99; 95% CI, 0.98-1.00). In a subgroup analysis of patients presenting without initial tachycardia or hypotension, only patients with undetectable admission eosinophil counts, but not those with an elevated white blood cell count, had significantly increased odds of inpatient mortality (OR, 5.76; 95% CI, 1.99-16.64). Conclusions and Relevance This study describes a simple, widely available, inexpensive model predicting CDI severity and mortality to identify at-risk patients at the time of admission.

BACKGROUND Although longer operative times are associated with increased postoperative morbidity, the influence of surgical residents on this association is unclear. OBJECTIVE The purpose of this study was to evaluate whether morbidity associated with operative times in laparoscopic colorectal surgery is increased by resident training. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted using a national database. PATIENTS Laparoscopic ileocolectomies, partial colectomies, and low anterior resections were identified in the National Surgical Quality Improvement Project (2005-2012). This cohort was stratified by the presence of resident involvement (postgraduate clinical year ≤5) and then divided into tertiles of operative time (low, medium, and high), allowing comparisons of cases by duration with resident involvement with cases of similar length without resident involvement. MAIN OUTCOME MEASURES Postoperative morbidity (infectious and noninfectious), length of hospital stay, and unplanned reoperations were the primary study outcomes. RESULTS A total of 20,785 procedures were identified. In aggregate, prolonged operative time was associated with both infectious (OR = 1.49, p < 0.001 with residents; OR = 1.38, p < 0.001 without residents) and noninfectious complications (OR = 1.51, p < 0.001 with residents; OR = 1.48, p < 0.001 without residents) when compared with short cases without residents. Longer hospital stay was observed both within the highest (additional 1.2 days (p < 0.001) with residents; 1.1 days (p < 0.001) without residents) and middle (additional 0.4 days (p < 0.001) with residents; 0.4 days (p = 0.001) without residents) tertiles of operative time. Within the highest tertile of operative length, there was no statistically significant difference in complication rates between cases with and without resident participation. LIMITATIONS The study was limited by its retrospective design and inability to define the complexity of case and extent of resident involvement. CONCLUSIONS Although longer operative times confer increased postoperative morbidity, there was no significant difference in complication rates within the highest tertile between cases with and without resident participation. Resident involvement does not appear to add to the risk of morbidity associated with longer and more complicated surgeries. See Video Abstract at http://links.lww.com/DCR/A440.

A Clostridium difficile-associated risk of death score was recently developed and validated by using a national cohort of both nonsurgical and surgical patients admitted with C difficile infection. However, risk scores specifically derived from surgical cohorts and designed for patients with C difficile infection are currently unavailable.The aim of this study was to develop a risk of death score for patients with C difficile infection who are being considered for total abdominal colectomy because of the failure of medical therapy.This is a retrospective cohort study.This study was conducted with the use of a national database.All patients undergoing total colectomy for C difficile infection were identified in the National Surgical Quality Improvement Program database from 2005 to 2014.Variables similar to the original scoring system were used in multivariable analyses to determine the risk of 30-day mortality for patients, and a model was constructed to estimate the predicted probability of mortality after surgery.Of 532 patients who underwent surgery, 32.7% experienced 30-day postoperative mortality. Patient covariates associated with significantly increased mortality included age greater than 80 years (OR 5.5, p = 0.003), need for preoperative mechanical ventilation (OR 3.1, p0.001), chronic steroid use (OR 2.9, p0.001), underlying cardiopulmonary disease (OR 2.0, p = 0.001), and acute renal failure (OR=1.7, p = 0.03). These and other comorbidities, including hepatic disease, a cancer diagnosis, and both insulin- and noninsulin-dependent diabetes mellitus, were used to construct a model to estimate the predicted probability of mortality, which ranged from 8.0% to 96.1% based on individual comorbidity profiles. These estimates differed substantially when compared with those obtained using the National Surgical Quality Improvement Program risk calculator, which estimated the risk of mortality among surgical patients as being consistently lower.This study was limited by its retrospective design.Our surgical scoring system allows preoperative risk stratification for patients being evaluated for colectomy for C difficile infection, potentially helping to avoid futile surgery. See Video Abstract at http://links.lww.com/DCR/A434.

Aim Smoking is known to have a deleterious effect onCrohn’s disease (CD). The present study addressed thespecific impact of smoking on the outcome of surgeryfor CD.Method A review of the National Surgical QualityImprovement Program (NSQIP) database (2005–2012)identified 7631 patients with CD who underwent surgi-cal resection. Patients were stratified based on smokingstatus and were compared with univariate statisticaltests. Generalized linear regression and multiple logisticregressions were used to model the impact of smokingon the surgical outcome [length of stay (LOS), mortal-ity, postoperative complications and readmission]. Toconfirm the validity of the regression models and toevaluate the influence of smoking in comparable patientcohorts, a propensity score match was also performed.Results There were 2047 (26.8%) patients with CDidentified as current smokers, and 5584 (74.2%) identi-fied as non- or ex-smokers. Smokers were more likely tohave a pulmonary comorbidity, preoperative weight lossand a higher American Society of Anesthesiologists clas-sification. No differences in mortality were observedbetween smokers and non- or ex-smokers in univariateanalysis. In multivariate analysis, smoking status was notsignificantly associated with LOS. Morbidity (OR 1.20,P = 0.003), particularly infectious (OR 1.30,P < 0.001) and pulmonary (OR 1.87, P < 0.001) com-plications, and readmission (OR 1.58, P = 0.004) weresignificantly associated with smoking status. These find-ings were validated on propensity-score matching analy-sis.Conclusion In patients with CD, the detrimental effectsof smoking on surgical outcomes are driven by infec-tious and pulmonary complications, and by an increasedlikelihood of readmission.Keywords Inflammatory bowel disease, tobacco,NSQIP, readmissions, complications, propensity-scoreWhat does this paper add to the literature?Tobacco use is associated with deleterious effects on theactivity and severity of Crohn’s disease. This study pro-vides a more focused estimate of the attributable impactof smoking on adverse postoperative results, demon-strating that they are driven by infectious and pulmo-nary complications.

Aim Compared with standard laparoscopic (SDL) approaches, less is known about the incidence of hernias after single-site laparoscopic (SSL) colorectal surgery. This study hypothesized that SSL colorectal surgery was associated with an increased risk of hernia development. Method Institutional retrospective chart review (September 2008–June 2013) identified 276 evaluable patients who underwent laparoscopic colorectal procedures. The following data were collected: demographic data, risk factors for the development of a hernia, operative details and postoperative course including the development of a hernia. Patients were stratified by laparoscopic technique to compare the characteristics of those undergoing SDL and SSL. Patients were subsequently stratified by the presence or absence of a hernia to identify associated factors. Results One hundred and nineteen patients (43.1%) underwent SDL and 157 patients (56.9%) underwent SSL surgery. The development of an incisional hernia was observed in 7.6% (9/119) of SDL patients compared with 17.0% (18/106) of SSL patients (P = 0.03) over a median 18-month follow-up. Similar proportions of patients developed parastomal hernias in both groups [SDL 16.7% (10/60) vs SSL 15.9% (13/80)]. Hernias were diagnosed at a median of 8.1 (SDL) and 6.5 (SSL) months following the index operation and were less likely to be incarcerated in the SSL group [SDL 38.9% (7/18) vs SSL 6.5% (2/31), P = 0.01]. Conclusion SSL colorectal surgery is associated with an increase in the incidence of incisional hernias but not parastomal hernias. Site of specimen extraction in SSL may contribute to the development of an incisional hernia.

Readmission after colectomy has become an important metric for measuring quality of care. Our aim was to investigate the impact of patient and hospital characteristics on 30-d readmission rates among patients undergoing colectomies in Pennsylvania.Data were obtained from the Pennsylvania Health Care Cost Containment Council, which included all patients undergoing colectomy during 2011 (n = 10,155). Characteristics of non-readmitted and readmitted patients were compared with univariate tests. The primary outcome was 30-d readmission, which was modeled using multivariable logistic regression.Of the 10,155 patients who underwent colectomy, 1492 (14.7%) were readmitted within 30 d of discharge. Readmission was influenced by the underlying diagnosis (P0.001). Additionally, readmission was more likely with a Charlson comorbidity index ≥ 2 (odds ratio [OR] = 1.57, P0.001), emergent admission (OR = 1.26, P = 0.001), an in-hospital complication (OR = 1.46, P0.001), lowest quartile for surgeon volume (OR = 1.24, P = 0.01), and construction of an ileostomy (OR = 2.31, P0.001). Factors associated with decreased likelihood of readmission included laparoscopic surgery (OR = 0.73, P0.001). No association with hospital volume was found.A 30-d readmission after colectomy is influenced by numerous patient- and surgeon-related factors. Reducing in-hospital complications, and improving patient education after ileostomy construction, provide substantial targets for intervention. Our data also suggest that there may be a critical range of colectomies performed annually by surgeons, greater than which no additional benefit is conferred in reducing readmissions, but below which there is an increased risk of readmission. Further research is needed to determine the influence of laparoscopic surgery in reducing readmission in equally matched patient populations.

Diseases of the Colon & ReCtum Volume 58: 1 (2015) of pseudomembranous colitis. although the bacteria are present the stool of ~3% of healthy adults, up to 50% of those exposed to an in-patient facility are asymptomatic carriers. higher rates have been cited in patients following a prolonged duration of exposure to antibiotics, and in those with severe underlying comorbid disease. infection can result in a wide range of presentations, from an asymptomatic carrier state or mild C difficile infection (CDi) to a severe and life-threatening condition (table 1). the prevalence and severity of CDi has dramatically increased since the early 2000s when a surge in morbidity and mortality rates occurred. C difficile infection most commonly involves the colon, where it is also commonly known as “pseudomembranous colitis” because of the common endoscopic finding of pseudomembranes covering the colonic mucosa. in rare circumstances, it may also involve the small bowel. Globally, CDi is increasingly more prevalent and severe; this may be due to the emergence of certain strains (ie, ribotypes) of the bacteria, which can result in not only a life-threatening infection, but also a surgical emergency. a number of studies have demonstrated an association between ribotype 027 and fulminant (heretofore referred as severe) CDi. a wide variety of practice measures and collaborative efforts have been implemented to reverse this trend, with occasional reports of success. Despite these efforts, reported cases of CDi increased 200% between 2000 and 2005, and have since continued to rise almost exponentially annually. Given the growing incidence of CDi, the economic burden of prevention and treatment has surged, and is increasingly important in the population of patients with colorectal diseases. this practice parameter will focus on the evaluation, management, and prevention of CDi.

Diverticular disease is commonly associated with the older population in the United States. As individual’s age, diverticulae, or herniation of the mucosa through the colonic wall, develop. In 10–25% of individuals, the diverticulae become inflamed, resulting in diverticulitis. The gut ecosystem relies on the interaction of bacteria and fungi to maintain homeostasis. Although bacterial dysbiosis has been implicated in the pathogenesis of diverticulitis, associations between the microbial ecosystem and diverticulitis remain largely unstudied. This study investigated how the cooperative network of bacteria and fungi differ between a diseased area of the sigmoid colon chronically affected by diverticulitis and adjacent non-affected tissue. To identify mucosa-associated microbes, bacterial 16S rRNA and fungal ITS sequencing were performed on chronically diseased sigmoid colon tissue (DT) and adjacent tissue (AT) from the same colonic segment. We found that Pseudomonas and Basidiomycota OTUs were associated with AT while Microbacteriaceae and Ascomycota were enriched in DT. Bipartite co-occurrence networks were constructed for each tissue type. The DT and AT networks were distinct for each tissue type, with no microbial relationships maintained after intersection merge of the groups. Our findings indicate that the microbial ecosystem distinguishes chronically diseased tissue from adjacent tissue.

Background Palliative care is associated with decreased cost and improved quality of life, although its use in stage IV rectal cancer is understudied. Materials and methods Stage IV rectal cancer patients (2004-2011) who did not undergo surgery with curative intent were identified within the National Cancer Database. Patients receiving palliative therapy were stratified by the type of intervention, as were patients undergoing chemotherapy that was not designated as palliative. Logistic regression was used to identify factors associated with the receipt of palliative therapy. Results A total of 11,245 patients were analyzed, of which 2314 (20.6%) received palliative therapy. Use of palliative therapy as a category of treatments did not change significantly from 2004-2012 (19.4%-23.0%; P = 0.14), but the use of palliative chemotherapy nearly doubled (4.7%-8.7%; P 60 y and increasing chronic comorbidities; these subgroups also had lower odds of receiving chemotherapy that was not designated as palliative. Differences in gender and race were not associated with variations in the receipt of palliative therapy. Conclusions For stage IV rectal cancers managed without curative intent, use of palliative therapies remains consistently low, with a preference for sicker patients.

As a consequence of their widespread use, a critical limitation in current antibiotic therapy is bacterial resistance. In the case of Clostridium difficile infection (CDI), current antibiotic regimens may not necessarily suffer due to drug resistance, though they have become increasingly ineffective due to the dysbiosis they induce, resulting in notoriously high recurrence rates. As a result, interest in alternative treatment modalities has recently surfaced. Amongst these emerging treatments, newer investigations are being invested in the older concept of bacteriophage therapy. This approach, first identified in the early 19th century, offers a more microbe-specific treatment option that can, theoretically, pointedly target C. difficile while sparing the other bacterial organisms of the human gut. The aim of this article is to explain the intellection behind bacteriophage therapy for the treatment of bacterial infections in humans, to review the historical research on bacteriophage therapy, and to introduce the reader to recent investigations into bacteriophage therapy for the treatment of CDI.

Background Neoplasia complicating ulcerative colitis (UC-neoplasia) is a problem that is poorly addressed by present surveillance techniques. The association of greater than 300 single nucleotide polymorphisms (SNPs) with inflammatory bowel disease (IBD) suggests the possibility that certain genetic polymorphisms might identify patients with UC destined for malignant degeneration. This present study tested the hypothesis that presently known IBD-associated SNPs may correlate with UC-neoplasia. Materials and methods A total of 41 patients with UC-neoplasia (mean age 56 ± 2.1 years) were identified from our divisional IBD Biobank (low-grade dysplasia n = 13, high-grade dysplasia n = 8, colorectal cancer [CRC] n = 20). These patients were individually age, sex, and disease duration matched with UC patients without neoplasia. Primary sclerosing cholangitis and family history of CRC were recorded. Patients were genotyped for 314 of the most commonly IBD-associated SNPs by a custom SNP microarray. Logistic regression and Fischer exact test were used for statistical analysis. Results After Bonferroni correction, none of the 314 IBD-associated SNPs correlated with UC-neoplasia when compared with matched UC controls. The incidence of primary sclerosing cholangitis was greater in the UC-neoplasia group (10/41, 24% vs 3/41, 7%; P = .03) compared with UC controls. The severity of neoplasia (low grade dysplasia versus high grade dysplasia versus CRC) correlated with disease duration (7.9 vs 13.4 vs 20.7 years, respectively). Conclusion The lack of correlation between well-known IBD-associated SNPs and UC-neoplasia demonstrated in this study suggests that the development of neoplasia in patients with UC is associated with genetic determinants other than those that predispose to inflammation or results from posttranslational modifications or epigenetic factors rather than germline polymorphisms.

Risk factors for complications differ between laparoscopic (LC) and open colectomy (OC) patients, given the selection bias between these groups. How risk factors for these outcomes differ between inpatient and post-discharge phases of care requires further study. A retrospective cohort study (2005–2010) using NSQIP data was performed comparing OC and LC patients. Multivariable logistic regression was used to compare covariates associated with mortality and overall complication rates both before and after hospital discharge. Patients in the LC cohort were younger (64.2 vs. 62.5 years; P

Background We aimed to determine if an increased incidence of incisional hernias is present in patients undergoing sigmoidectomy for diverticulitis vs cancer. The pathophysiology of diverticulitis is poorly understood, but might involve a collagen vascular abnormality that can predispose to incisional hernia. Study Design In this IRB-approved, retrospective study, patients who underwent sigmoid colectomies for diverticulitis or cancer between January 2003 and September 2012 were studied. Exclusion criteria included the development of surgical site infections and neoadjuvant chemoradiotherapy. A multivariate logistic regression was used with covariate adjustments for known risk factors for hernia development. Results Four hundred forty-two patients (mean age 59.3 ± 13.9 years) with a median follow-up of 30 months were analyzed. The incidence of incisional hernia was 15.1% in diverticulitis patients vs 5.8% in the cancer cohort (41 of 271 vs 10 of 171; p = 0.003). Univariate analysis of risk factors associated with postoperative incisional hernia included steroid use (p = 0.007), wound packing (p = 0.001), higher American Society of Anesthesiologists classification (p = 0.001), absorbable suture closure (p = 0.02), blood transfusion (p = 0.04), stoma formation (p = 0.02), increased body mass index (p = 0.008), and history of incisional hernia (p = 0.00008). Multivariate logistic regression demonstrated a persistent association between diverticulitis and hernia development (p = 0.01). Odds of a hernia developing after sigmoidectomy for diverticulitis were 2.82 times greater than in the cancer cohort (95% CI, 1.3–6.6). Conclusions The incidence of an incisional hernia developing after a sigmoid colectomy is significantly higher when performed for diverticulitis as compared with cancer. This might be due to a connective tissue disorder, which predisposes to development of both diverticula and hernias.

The present study sought to compare the length of stay (LOS) and hospital costs for elective single-site (SSL) and standard laparoscopic (SDL) colorectal resections performed at a tertiary referral center. An IRB-approved, retrospective cohort study of all elective SDL and SSL colorectal resections performed from 2008 to 2012 was undertaken. Patient charges and inflation adjusted hospital costs (US dollars) were compared with costs subcategorized by operating room expense, room and board, and pharmacy and radiology utilization. A total of 149 SDL and 111 SSL cases were identified. Compared with SSL, SDL surgeries were associated with longer median operative times (SSL: 153 min vs. SDL: 189 min, p = 0.001); however, median operating room costs were similar (p > 0.05). Median postoperative LOS was similar for both groups (SSL: 3 days; SDL: 4 days; p > 0.05). There was no difference between SSL and SDL with respect to either total patient charges (SSL: $34,847 vs. SDL: $38,306; p > 0.05) or hospital costs (SSL: $13,051vs. SDL: $12,703; p > 0.05). Median costs during readmission were lower for SSL patients (SSL: $3,625 vs. SDL: $6,203, p = 0.04). SSL provides similar LOS as well as similar costs to both patients and hospitals compared with SDL, making it a cost-feasible alternative.

BACKGROUND:: The tubal occlusion contraceptive provides a hysteroscopic technique for female sterilization. Efficacy of the tubal occlusion contraceptive relies on proper placement within the proximal aspect of the fallopian tubes. As long-term data become available rates of complications are better defined. CASE:: This is a case of a patient who underwent placement of a tubal occlusion contraceptive. As a result of persistent pain and nausea imaging was performed and malposition of the tubal occlusion contraceptive was identified. During laparoscopy bowel perforation at the terminal ileum was diagnosed. Laparoscopic ileocecectomy was performed. CONCLUSION:: There should be a low threshold for evaluation of complications after tubal occlusion contraceptive placement. Although rare bowel perforation after placement of the tubal occlusion contraceptive can occur. Laparoscopic management should be considered.

For rectal cancer, it is unknown how use of radiation, treatment cost, and survival differ based on hospital teaching designation.Private insurance claims data linked with the Pennsylvania Cancer Registry were used to identify rectal cancer patients undergoing surgery from 2004 to 2006. Patients with missing data of interest were excluded. Hospitals were characterized as follows: large (≥200 beds) versus small size (200 beds), teaching versus nonteaching, and urban versus rural. Logistic regression was used to model the use of neoadjuvant radiotherapy, and Cox proportional hazards models were used to compare cancer-specific survival between hospital types.A total of 432 patients were analyzed. There was no difference in the distribution of cancer stages among the various hospital types (all p 0.20). Teaching hospitals were associated with significantly higher utilization of neoadjuvant radiotherapy for stage II and III cancers compared with nonteaching facilities (57 vs. 28 %; p 0.0001). On multivariate analysis, teaching status was the only hospital designation associated with use of neoadjuvant radiation (p 0.001); hospital size and rural/urban designation were not significant. Nonteaching hospitals were more likely to use adjuvant radiotherapy for stage II and III disease (13 vs. 30 %; p 0.01). Teaching hospitals had lower odds of death from rectal cancer when evaluating all stages [hazard ratio (HR) = 0.35; p 0.0001] with similar costs of inpatient treatment (teaching: US $30,769 versus nonteaching: US $26,892; p = 0.22).Teaching designation was associated with higher incidence of neoadjuvant radiotherapy for stage II and III disease, with improved cancer-specific survival compared with nonteaching hospitals, and with similar treatment costs.

After neoadjuvant chemoradiotherapy for rectal cancer, the interpretation of surgical pathology poses difficulties in deciding the need for adjuvant chemotherapy (AC). The aim of this study was to determine whether there is a survival benefit to providing AC in patients with node-negative disease on surgical pathology. Patients with clinical stage II and III rectal adenocarcinoma who received neoadjuvant chemoradiation and definitive surgical resection from 2006 to 2012 were identified in the National Cancer Data Base. Patients were stratified by both receipt of AC and nodal status on surgical pathology. Propensity score matching was used to form two cohorts (AC vs. no AC) with otherwise balanced characteristics. Overall survival was compared by Kaplan–Meier analysis, and multivariable survival analysis was performed by a Weibull model. After propensity score matching, 4172 patients who received adjuvant therapy (2645 node negative and 1527 node positive) and 4172 patients who did not receive adjuvant therapy (3063 node negative and 1109 node positive) were identified. Among patients with either node-negative or node-positive disease, the use of AC was associated with a significant improvement in overall survival. These results were also observed after using a multivariable survival model to control for clinical stage as well as patient- and facility-related characteristics. In both patients with node-negative and node-positive disease on surgical pathology, the use of AC is associated with a survival benefit. In the absence of contraindications, AC should continue to be routinely recommended to patients after neoadjuvant chemoradiotherapy for locally advanced rectal cancers.

BACKGROUND Patients admitted with Clostridium difficile infection are managed in a variety of settings. If their care is inadequate, these patients can rapidly deteriorate. OBJECTIVE The purpose of this study was to evaluate whether mortality for patients admitted with C difficile differed between medical and general/colorectal surgery services. DESIGN This was a retrospective cohort study with multivariable logistic regression used to evaluate the effect of admitting service on in-hospital mortality rates, with propensity score matching used to validate this relationship. SETTINGS The study was conducted at a single, tertiary care center. PATIENTS Inpatients with a positive C difficile stool test within 24 hours of admission to medical or surgical services were identified (2005-2015) using institutional electronic data sources. MAIN OUTCOME MEASURE We measured inpatient mortality rate. RESULTS Of 1175 patients, 985 (83%) were admitted to medical services, whereas 190 (17%) were admitted by surgeons. Medical patients were older (63.9 vs 58.9 years; p = 0.001) and had a mean of 0.6 additional comorbidities (p < 0.001); cohorts were similar regarding vasopressors, peak white blood cell counts, and rate of intensive care unit admissions. Mortality was lower among surgery patients (2.6% vs 6.8%; p = 0.028), and logistic regression demonstrated lower odds of mortality for this group OR = 0.18 (95% CI, 0.05-0.58)). After propensity score matching for age, comorbidities, and severity of disease, this difference was confirmed (2.6% vs. 9.5%). A higher incidence of total colectomy for surgery patients (14.2% vs 0.4%) was a causal factor in their longer lengths of stay and higher total hospital costs. The time between orders for stool testing and metronidazole therapy was shorter in the surgery group (1.8 vs 3.8 hours; p = 0.002), although this trend was not observed with vancomycin therapy. LIMITATIONS This was a retrospective study from a single institution, thereby limiting generalizability, with a lack of information regarding premorbid creatinine levels, ileus, or megacolon. CONCLUSIONS In-hospital mortality rates for patients admitted with C difficile were lower on surgery services, perhaps in part related to higher colectomy rates.

Recurrent Clostridium difficile colitis (RCDC) is common, but data regarding recurrence rates and predisposing factors are sparse. A retrospective case–control study was performed, identifying all inpatients and outpatients ≥18 years of age with C. difficile colitis (CDC) confirmed by a positive stool sample collected at our institution from January 2008 to August 2011. Factors associated with RCDC, the number of RCDC episodes, and the need for admission for RCDC were sought. A total of 739 patients (male, 47 %) were studied, of whom 527 (71 %) received inpatient treatment for their index episode of CDC. There was no difference (p = 0.53) between RCDC rates for inpatients (17.6 %) and outpatients (19.8 %). While severity score and albumin were associated with RCDC in our population, use of proton pump inhibitors (PPIs) correlated with decreased RCDC (p = 0.006) and decreased need for admission (p = 0.005). The addition of vancomycin to metronidazole therapy did not lower RCDC rates (p = 0.52) or decrease the need for admission (p = 0.78). Hypoalbuminemia strongly correlated with higher recurrence rates, while PPI therapy actually reduced RCDC, representing previously underappreciated potential therapeutic targets for lowering CDC recurrence. The addition of vancomycin to metronidazole did not improve RCDC rates.

Introduction. The concept of staple line reinforcement is a growing area of interest. This study evaluated the feasibility and effect of using bioabsorbable Seamguard (BSG) to bolster end-to-end stapled rectal anastomoses in a porcine model. Methods. Eleven female 45-kg Yucatan domestic pigs were used. Each animal served as its own control by creating a BSG and nonreinforced anastomosis using a 29-mm end-to-end anastomotic stapling device. Reinforced anastomoses were randomized to proximal and distal positions along the rectum. Each staple line reinforcement agent consisted of adding BSG to the stapling device according to the manufacturer’s instructions. Barium enemas were then performed and the 2 anastomotic sites harvested. Each anastomosis underwent burst testing. The internal diameter of each anastomosis was measured and underwent pathologic review. Results. Bolstered anastomoses offered no strength advantage as burst pressures were no different as compared with unbolstered anastomoses. There was also no difference in anastomotic internal or external diameters. Only 1 stapled anastomosis burst during testing and none in the bolstered group. On histological analysis, there was a significant increase in inflammatory infiltrate in the bolstered group as compared with the stapled group ( P = .041), with a higher incidence of lymphocytes ( P = .047) and giant cells ( P = .037). There was no difference in mucosal loss at the anastomotic site, neovascularization, fibroblast presence, extent of fibrosis, muscle layer disruption, percentage of anastomosis replaced by collagen, and elastin deposition. Conclusions. The routine use of BSG bolsters in stapled rectal anastomoses is safe and results in equivalent anastomotic strength as traditional stapled anastomoses.

Single-site laparoscopy (SSL) represents an innovation whose wider adoption may be limited by technical challenges and a current dearth of outcomes data.A retrospective review of prospectively collected data was performed on all consecutive laparoscopic colorectal resections, including elective and emergent surgeries. Patient demographics and operative details were collected, and outcomes were analyzed for 30 days following surgery.Forty-one single-site laparoscopic procedures were performed, with 12 (29%) being nonelective. Surgeries included seven right colectomies, eight sigmoidectomies, four ileocolectomies, five total colectomies, two low anterior resections, and two abdominoperineal resections. The most frequent indication for surgery was inflammatory bowel disease (31.7%), followed by cancer (24.4%) and diverticular disease (24.4%). Thirty-seven percent of the patients had undergone previous abdominal surgery, with 64% of these having undergone previous laparotomy. One (2.5%) patient required conversion to multiple trocar laparoscopy, and five (12%) required conversion to laparotomy. Mean length of hospital stay was 4.2 days for SSL without a conversion. There was one anastomotic leak, no postoperative bleeding, no surgical site infections, and no deaths. The readmission rate was 14%.SSL is safe when applied to unselected patients undergoing colorectal surgery, including those patients who have undergone a previous laparotomy.

To assess differences in hospital costs for inpatients with Clostridium difficile (CD) colitis based on hospital size, rural or urban hospital setting, and hospital designation as a teaching institution.Data from the Pennsylvania Health Care Cost Containment Council (PHC4) were reviewed for 2005 to 2008. Cost-to-charge ratios were used to derive costs from hospital charges, adjusting costs for inflation. Propensity score-matched CD colitis and non-CD colitis cohorts were compared. Costs were modeled by generalized linear regression.A total of 78,273 patients with CD colitis were identified. The average hospital cost per admission for patients with CD colitis was $22,094 compared to $10,865 for non-CD colitis patients. The 2005 to 2008 admission costs for CD colitis rose 9%, while the prevalence of CD colitis decreased by 13%. The costs for patients with CD colitis were consistently twice as much as those for non-CD colitis patients (P.0001). Small facilities had the greatest costs overall (P.0001). Urban and teaching facilities had greater costs than rural and nonteaching facilities (P.0001), which corresponded to a greater proportion of patients with greater comorbidities (P.0001). Among rural hospitals, the smallest facilities had the greatest costs (P.0001), as did urban nonteaching hospitals (P.0001). By contrast, costs did not differ among urban teaching hospitals of varying sizes (P = .35).Costs for inpatient CD colitis in Pennsylvania have been increasing. Teaching and urban hospitals treat the group of patients with CD colitis with the greatest comorbidity, accounting for their greater cost of care. The cost of treating CD colitis is comparable among different sizes of teaching hospitals, which may reflect a more standardized approach toward treatment choices.

Background Surgical site infections (SSIs) are a well known complication of gastrointestinal surgery and associated with an increased morbidity, mortality and overall cost. Diabetes mellitus (DM) is a risk factor for SSI. However, there is no clear consensus as to which other risk factors play a significant role. The goal of this study was to identify risk factors associated with SSI in patients with DM undergoing colorectal resection. Study Design A retrospective review was conducted of DM patients who underwent colorectal resection from June 2000 to June 2009 at Milton S Hershey Medical Center, Division of Colorectal Surgery. Individual measures were analyzed using chi-square, t -test, and Mann-Whitney U tests, and statistical significance was confirmed using a multiple logistical regression model. Results There were 183 DM patients included in the study, 28 (15%) of whom developed SSI. Glucose levels were significantly higher in the SSI group for each time interval, 0 to 6 hours (211 mg/dL, p=0.03), 0 to 48 hours (176 mg/dL, p=0.001), and 48 to 96 hours (167 mg/dL, p=0.012) postoperatively. Other measures significantly associated with SSI included the use of drains (p = 0.05) and the use of prophylactic antibiotics for more than 24 hours (p = 0.02). Body mass index and stoma creation approached statistical significance (p = 0.08, 0.07, respectively). The type of hypoglycemic regimen, immunosuppression, and emergency surgery were not associated with an increased rate of SSI. Conclusions Higher than normal glucose control at all postoperative time intervals was associated with SSI. The majority of glucose levels were below the American Diabetes Association recommended level of 200 mg/dL, but patients still developed SSI. Type of perioperative glucose control did not affect the incidence of SSI. These data suggest that DM patients undergoing colectomy should have glucose tightly controlled, avoid placement of drains, and receive antibiotics for less than 24 hours.

PURPOSE: Ileal pouch-anal anastomosis continues to be confounded by Crohn's disease-like complications after surgery. Such patients experience significant morbidity and often require either pouch excision or diversion. This study evaluated the effectiveness in our hands of infliximab and/or azathioprine/6-mercaptopurine in treating this patient population. METHODS: We conducted a retrospective chart review of all patients who underwent IPAA who experienced Crohn's disease-like complications (pouch fistulas, stricturing small-bowel disease, or pouchitis unresponsive to antibiotics) after ileostomy closure. Patients were segregated according to treatment (azathioprine/6-mercaptopurine only, infliximab only, or both azathioprine/6-mercaptopurine and infliximab) and evaluated for clinical response defined by significant symptomatic improvement and avoidance of stoma. RESULTS: Of 382 IPAAs, 32 (8.4%) patients developed Crohn's disease-like complications a mean of 17 months after stoma closure. Of these, 22 were treated with azathioprine/6-mercaptopurine and/or infliximab with one lost to follow-up. Overall mean follow-up was 97 ± 11.8 months. Failure rate (requiring stomas) was highest in the fistula group treated with infliximab and azathioprine/6-mercaptopurine (6/13, 46%). Patients with stricturing disease (6) or severe pouchitis (2) were all effectively treated with azathioprine/6-mercaptopurine (5/6) or infliximab (1 Financial Disclosure: None reported. patient allergic to azathioprine/6-mercaptopurine) and none of these patients required stomas. In the group not receiving stomas, bowel frequency improved from 8.3 ± 1 to 5.7 ± 0.5 per day (P < .05). CONCLUSION: Fistulizing disease after IPAA has the highest failure/stoma rate (46%) despite treatment with infliximab and/or azathioprine/6-mercaptopurine. IPAA patients with stricturing disease and/or antibiotic resistant pouchitis were successfully treated without stomas and all had resolution of symptoms, which suggests that fistulous disease after IPAA should be treated with infliximab, but stricturing disease and antibiotic resistant pouchitis may be effectively treated with azathioprine/6-mercaptopurine only. Such a protocol will potentially minimize the risks associated with infliximab in this difficult group of patients.

The effect on cancer-specific survival (CSS) from the number of resected nodes (node yield) and the number of nodes involved with colon cancer has not been studied with respect to age. Data from 1992 to 2006 from the Surveillance, Epidemiology and End Results (SEER) registry were analyzed for colon cancer patients undergoing curative resection, comparing younger (

Introduction: The most feared complication of colorectal anastomoses is leaks resulting in severe morbidity. The concept of staple-line reinforcement is a growing area of interest. In this study, the authors evaluated the feasibility and effect of using 1.5:1 meshed AlloDerm to bolster end-to-end stapled rectal anastomoses in a porcine model. Methods: A total of 30 female 45-kg domestic pigs were studied, and each served as its own control by creating a bolstered and unbolstered anastomosis in each animal. All anastomoses were created with a 29-mm end-to-end stapling device. Bolstered anastomoses were randomized to proximal and distal positions along the rectum, and each rectorectal anastomosis was separated by an average of 10 cm. The animals were survived to 3, 5, and 30 days. Barium enemas were then performed and the 2 anastomotic sites harvested. Each anastomosis underwent burst testing. The internal diameter of each anastomosis was measured, and a biochemical analysis was performed for elastin and collagen content. Results: Bolstered anastomoses offered no strength advantage as burst pressures were no different when compared with unbolstered anastomoses. There was also no difference in anastomotic internal diameter, biochemical analysis of elastin or collagen, or presence of adhesions when comparing bolstered with unbolstered anastomoses. There were 4 subclinical leaks—1 in the unbolstered group and 3 in the bolstered group. Conclusions: The routine use of 1.5:1 meshed AlloDerm sandwich bolsters in stapled rectal anastomosis does not confer any detectable advantage in anastomotic strength. Further studies are needed to determine equivalence to traditional stapled anastomoses.