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Patients with coagulopathy requiring emergent appendectomy constitute a challenging patient population. It is unclear whether laparoscopic appendectomy (LA) is as safe as open appendectomy (OA) in these patients.We queried the ACS-NSQIP database for adults with coagulopathy undergoing emergent appendectomy from 2014 to 2017. Demographic characteristics and operative outcomes were compared between the two groups. Propensity weighting for LA versus OA was estimated using augmented inverse probability of treatment weights (AIPW).A total of 137,429 patients were included, of which 7049 (5%) had coagulopathy. In patients with coagulopathy, LA was the most common approach (89%). After AIPW, there was no difference in the adjusted risk of either postoperative transfusion or 30-day reoperation between OA and LA. LA was associated with reduced operative time (56 versus 75 min), length of stay (3.5 versus 7.0 d), and surgical site infection rate (6% versus 13%) compared to OA.Patients with coagulopathy represent a significant proportion of those undergoing an appendectomy. The majority of patients with coagulopathy who require appendectomy undergo LA, and this approach appears to be safe with regard to transfusion requirement and reoperation.

OBJECTIVE Colorectal surgery (CRS) training has seen many changes over the years. This study sought to identify aspects of CRS residency curriculum that were most valued by recent graduates and what changes could be made to improve training. DESIGN Semistructured interviews were performed with board-certified colorectal surgeons 2 to 7years removed from their CRS residency. Interview responses were qualitatively analyzed and converted to coded, categorizable data. Subjects were recruited via a snowball sampling method. SETTING Interviews were conducted in person and via telephone with surgeons in a variety of practices across the United States and Canada. Analysis was performed by a team at Lahey Clinic, Burlington, MA, an academic, tertiary care center. PARTICIPANTS Board certified colorectal surgeons 2 to 7years removed from CRS residency. RESULTS Twenty surgeons from 11 different CRS residencies were interviewed. At the time of the interview, surgeons were employed in 13 states and 1 foreign country. When asked what aspects of their CRS residency were of value, surgeons produced 74 comments emphasizing: volume of cases (65% of subjects), variety of cases (55%), development of technical skills (40%), management of specific diseases (35%), faculty (30%), mentorship (30%), and practice management (15%). With regard to technical skills, surgeons cited pelvic surgery (40%) and minimally invasive techniques (45%) as the exposures that helped them become successful. When discussing what could be added to training, subjects made 54 comments identifying: more robotic exposure (35%), more anorectal disease (30%), more pelvic floor exposure (25%), and practice management/billing (35%) as items to incorporate. Sixty five percent of subjects believed that “nothing” should be eliminated from their training. CONCLUSIONS Young colon and rectal surgeons valued their training highly and strongly declined to eliminate any substantial part of the existing curriculum. They also expressed a strong desire to add more elements to the CRS residency including further robotic training, more anorectal, more pelvic floor, and further training in practice management.

Hypothermia has been associated with an increase in the rate of infectious complications following colectomy. We hypothesized that a substantial fraction of temperature loss in patients undergoing elective colectomy occurs prior to operation. Temperature data were collected from 105 consecutive patients undergoing elective colectomy at a single institution. The study population consisted of 105 patients; 67(64%) male, median age 59 years (range 17–95 years), median body mass index 27 kg/m2 (range 15–48 kg/m2). Median preoperative temperature was 36.7 °C (range 35.2–39.2 °C), dropping to 35.7 °C (range 34.0–37.3 °C) immediately following intubation and then rising to 36.2 °C (range 34.0–38.0 °C) prior to leaving the operating room. The median first postoperative temperature was 36.3 °C (range 34.4–37.7 °C). Temperatures were significantly different from one another (p

BACKGROUND Approximately half of Crohn's patients require intestinal resection, and many need repeat resections. OBJECTIVE The purpose of this study was to evaluate the increased risk of clinical anastomotic leak in patients with a history of previous intestinal resection undergoing repeat resection with anastomosis for Crohn's disease. DESIGN This was a retrospective analysis of prospectively collected departmental data with 100% capture. SETTINGS The study was conducted at the department of colorectal surgery in a tertiary care teaching hospital between July 2007 and March 2016. PATIENTS A cohort of consecutive patients with Crohn's disease who were treated with intestinal resection and anastomosis, excluding patients with proximal fecal diversion, were included. The cohort was divided into 2 groups, those with no previous resection compared with those with previous resection. MAIN OUTCOME MEASURES Clinical anastomotic leak within 30 days of surgery was measured. RESULTS Of the 206 patients who met criteria, 83 patients had previous intestinal resection (40%). The 2 groups were similar in terms of patient factors, immune-suppressing medication use, and procedural factors. Overall, 20 clinical anastomotic leaks were identified (10% leak rate). There were 6 leaks (5%) detected in patients with no previous intestinal resection and 14 leaks (17%) detected in patients with a history of previous intestinal resection (p < 0.005). The OR of anastomotic leak in patients with Crohn's disease with previous resection compared with no previous resection was 3.5 (95% CI, 1.3-9.4). Patients with 1 previous resection (n = 53) had a leak rate of 13%, whereas patients with ≥2 previous resections (n = 30) had a leak rate of 23%. The number of previous resections correlated with increasing risk for clinical anastomotic leak (correlation coefficient = 0.998). LIMITATIONS This was a retrospective study with limited data to perform a multivariate analysis. CONCLUSIONS Repeat intestinal resection in patients with Crohn's disease is associated with an increased rate of anastomotic leakage when compared with initial resection despite similar patient, medication, and procedural factors. See Video Abstract at http://links.lww.com/DCR/A459.

To prospectively evaluate the effect of introducing a clinical skills "passport" on medical students' reporting of their experience with basic clinical skills.A prospective longitudinal intervention study was conducted. Medical students were administered a questionnaire at the conclusion of their 12-week surgery clerkship regarding their experience with 15 clinical skills, inquiring whether they had "learned on surgery clerkship", "learned before surgery clerkship", or "not learned". Preintervention baseline data were obtained for 2 consecutive academic years (n = 213 students). In the third year, students (n = 124) were given a clinical skills passport to document performance of 8 of the 15 skills under the supervision of a surgical resident or faculty member. After excluding from analysis those students who learned a skill before their surgery clerkship, the fraction of students who reported learning clinical skills during their surgery clerkship before and after the introduction of the clinical skills passport was compared using Fisher exact test and chi-squared test, where appropriate (p ≤ 0.003 was considered significant; Bonferroni correction for multiple comparisons).Washington University School of Medicine.A total of 337 medical students completing the junior surgery clerkship over a 3-year period were included in the study.All 337 students completed a survey. Considering each skill individually, survey response rate was 5045/5055 (99.8%). Combining all responses for all skills, the fraction of students reporting that skills were learned on the surgery clerkship increased after the introduction of the clinical skills passport (1498/1938 [77%] preintervention vs. 974/1109 [88%] postintervention, p0.0001, chi square). After the introduction of the clinical skills passport, the fraction of students reporting that a skill was "learned on surgery clerkship" significantly increased for the 8 skills listed on the passport (1026/1699 [83%] preintervention vs. 685/714 [96%] postintervention, p0.0001, chi square), but did not increase for the 7 skills not listed on the passport (472/695 [68%] preintervention vs. 289/395 [73%] postintervention, p = 0.08, chi square). Considering each skill individually, after the introduction of the clinical skills passport, the fraction of students reporting that a skill was "learned on surgery clerkship" significantly increased for 4/15 skills (all listed on the clinical passport) and decreased for 0/15 skills (p0.003, Fisher exact test, 2 tailed).Institution of a clinical skills passport system during a surgery clerkship increased medical student reporting of their performance of basic clinical skills.

Auscultation for bowel sounds has been advocated by some clinicians as a method to determine the resolution of postoperative ileus.Our primary aim was to prospectively evaluate the relationships between bowel sounds and the ability to tolerate oral intake in patients after major abdominal surgery. Secondarily we aimed to evaluate relationships among bowel sounds, flatus and bowel movement, and oral intake.This was a prospective, blinded observational study.The study was conducted at Western Pennsylvania Hospital.A total of 124 adult patients undergoing major abdominal surgery were included.Data were collected by medical students blinded to the purpose of the study for 10 days postoperatively or until discharge, including the presence of bowel sounds (auscultation for 1 minute), flatus, bowel movement, and tolerance of oral intake (defined as ingestion of ≥1000 mL/24 h and each subsequent day without vomiting). Associations between paired variables were determined using ϕ coefficient testing.The study population consisted of 51 men and 73 women, with a mean age of 64 years (range, 20-92 y). The majority of patients (78/124 (63%)) underwent colorectal resection. The median length of hospital was 6 days. Bowel sounds were not associated with flatus, bowel movement, or tolerance of oral intake throughout the study period. The positive predictive value of bowel sounds in predicting flatus and bowel movement was low in the early postoperative period and remained25% in predicting tolerance of oral intake throughout the study period. The analysis was repeated, including only those patients undergoing colorectal procedures, and was essentially unchanged. Flatus correlated with bowel movement in the first 6 days postoperation, but neither flatus nor bowel movement was associated with tolerance of oral intake.The rate of tolerance of oral intake was relatively modest throughout the study period.Bowel sounds are not associated with flatus, bowel movement, or tolerance of oral intake after major abdominal surgery.

Rectal prolapse is usually of benign etiology. Rarely, sigmoido-rectal intussusception results from a malignant lead-point. We report the case of a patient with a partially obstructing sigmoid cancer causing a full thickness rectal prolapse requiring surgical intervention. An 82-year-old woman presented with 1 week of rectal bleeding, fecal incontinence, and weight loss. Computed tomography identified sigmoido-rectal intussusception. Colonoscopic biopsy revealed high-grade dysplasia. Magnetic resonance imaging demonstrated a 6-cm mass forming the lead point of the intussusceptum with epiploic appendages seen within the rectal lumen. She underwent laparoscopic low anterior resection with final pathology consistent with T2N0 adenocarcinoma, and recovered well. Among adult patients with rectal prolapse, suspicion for underlying malignancy should prompt a thorough investigation to inform the decision for resection, which may be safely performed by minimally invasive techniques.

To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Patients considered being at high risk for conversion to formal laparotomy were initially approached via a small midline incision (“peek port”) with the laparoscopic equipment readily available but unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy (HALS); if intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy. Data from 664 patients from a single surgeon brought to the operating room with the intention of proceeding with laparoscopic colectomy (either via straight laparoscopy or HALS) were retrieved from a prospective database. Comparison of conversion rates between groups was performed using χ2 analysis. The study population consisted of 361 men and 303 women with a mean age of 61 years. Inflammatory conditions accounted for 40% of the diagnoses and enteric fistulas were present in 12%. Of the 79 patients who underwent initial “peek port” exploration, 38 (48%) underwent immediate extension to formal laparotomy, whereas 41 (52%) underwent HALS colectomy, with one subsequent conversion from HALS to formal laparotomy. Of the 585 patients initially approached laparoscopically, 14 (2%) required conversion to laparotomy. Of the 626 patients from both groups who underwent laparoscopy, the overall conversion to laparotomy rate was 15/626 (2%). The “peek port” approach to the patients with a potentially hostile abdomen allows for prompt assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy during colectomy. This technique may reduce expense and morbidity for patients who ultimately require laparotomy, while allowing some patients with complex disease to be managed laparoscopically who would not normally be considered for a minimally invasive procedure.

OBJECTIVE: To determine the disease free survival (DFS) and recurrence after the treatment of patients with rectal cancer with open (OPEN) or laparoscopic (LAP) resection. BACKGROUND: This randomized clinical trial (ACOSOG (Alliance) Z6051), performed between 2008–2013, compared LAP and OPEN resection of Stage II/III rectal cancer, within 12 cm of the anal verge (T1–3, N0–2, M0) in patients who received neoadjuvant chemoradiotherapy. The rectum and mesorectum were resected using open instruments for rectal dissection (included hybrid hand-assisted laparoscopic) or with laparoscopic instruments under pneumoperitoneum. The 2 year DFS and recurrence were secondary endpoints of Z6051. METHODS: The DFS and recurrence were not powered and are being assessed for superiority. Recurrence was determined at 3, 6, 9, 12 and every 6 months thereafter using carcinoembryonic antigen, physical exam, computed tomography and colonoscopy. 486 patients were randomized to LAP (243) or OPEN (243), with 462 eligible for analysis (LAP=240 and OPEN=222). Median follow up is 47.9 months. RESULTS: 2 year DFS was LAP 79.5% (95%CI, 74.4–84.9) and OPEN 83.2% (95% CI, 78.3–88.3). Local and regional recurrence was 4.6% LAP and 4.5% OPEN. Distant recurrence was 14.6% LAP and 16.7% OPEN. DFS was impacted by unsuccessful resection (HR 1.87, 95% CI, 1.21–2.91): (composite of incomplete specimen (HR 1.65, 95% CI, 0.85–3.18); positive circumferential resection margins (HR 2.31, 95% CI, 1.40–3.79); positive distal margin (HR 2.53, 95% CI, 1.30–3.77). CONCLUSION: Laparoscopic assisted resection of rectal cancer was not found to be significantly different to OPEN resection of rectal cancer based on the outcomes of DFS and recurrence. MINI-ABSTRACT: Reporting of the secondary endpoint of the disease free survival of a multi-center non-inferiority randomized clinical trial (ACOSOG (Alliance) Z6051) performed between 2008–2013 comparing LAP and OPEN low anterior and abdominoperineal radical resection for Stage II/III rectal cancer. Disease free survival two years after resection was found to be similar for patients treated with laparoscopic or open techniques for proctectomy.

The aim of this article is to evaluate geographic variation in the incidence of diverticulitis and examine behavioral and environmental factors associated with high rates of diverticulitis across the United States. We used state hospital discharge data from 20 states to determine rates of inpatient diverticulitis from January 2002 to December 2004 at patient's county of residence. Next, we merged the county level data with behavioral and environmental survey data from the Behavioral Risk Factor Surveillance System (BRFSS). Finally, we determined the association between behavioral and environmental factors (i.e., teeth removal, dental cleaning, air quality, smoking, alcohol, vaccine, vitamins, and mental health) and high rates of diverticulitis. From January 1, 2002, to December 31, 2004, a total of 345,216 hospitalizations for acute diverticulitis were recorded for 1,055 counties. We identified rates of diverticulitis that ranged from 35.4 to 332.7 per 100,000 population. On univariate analysis, high diverticulitis burden was associated with regions of the country with substantial tooth loss from dental disease (45.8% for high diverticulitis counties vs. 37.5% for low diverticulitis counties; p = 0.0001). There is considerable variability in diverticulitis cases by county of residence across the nation. Potential triggers of diverticulitis may be associated with tooth removal and sun exposure.

We sought to determine the accuracy of the Model for End-Stage Liver Disease and the Mayo Clinic Postoperative Mortality Risk in Patients with Cirrhosis Calculator in patients with ascites who underwent colorectal surgery. The National Surgical Quality Improvement Program database was queried for patients with ascites who underwent a major colorectal operation. Predicted 90-day mortality rate based on the Model for End-Stage Liver Disease and 30-day mortality based on the Mayo Clinic Postoperative Mortality Risk in Patients with Cirrhosis Calculator were compared with observed 30-day mortality. The cohort contained 3137 patients with ascites who underwent a colorectal operation. The Model for End-Stage Liver Disease predicted that 252 (8 %) of patients with ascites undergoing colorectal operations would die within 90 days postoperatively, yet we observed 821 deaths (26 % mortality) within 30 days after surgery (p < 0.001). The Mayo Clinic Postoperative Mortality Risk in Patients with Cirrhosis Calculator predicted that 491 (16.6 % mortality) of patients with ascites undergoing colorectal operations would die within 30 days postoperatively, yet we observed 707 (23.9 % mortality) at 30 days (p < 0.01). We concluded that the current risk prediction models significantly under predict mortality in patients with ascites who underwent colorectal surgery.

Background ACS-NSQIP classifies hospitals as “high outliers” if their performance is significantly worse than expected. We determined how often hospitals return to as-expected performance after being newly identified as outliers. Methods Outlier status was identified in ACS-NSQIP semi-annual reports (SARs) 2008–2011 for 13 postoperative adverse events. Pearson correlation and R 2 measured the relationship between frequency of changes in outlier status, frequency of outlier identification, and adverse event rate. Results Among 284 hospitals, 75% were classified as high outliers for an adverse event at least once. New high outliers frequently did not remain outliers in the next SAR. Of new outliers, mortality had the highest percentage return to as-expected performance (62.7%), while surgical site infection had the lowest (20.5%). The likelihood of an outlier hospital returning to as-expected performance was inversely related to the percentage of hospitals classified as outliers. The percentage of hospitals classified as outliers for an event explained 60% of variation in outlier hospitals returning to as-expected performance. Conclusions Outlier status may be less meaningful for adverse events with relatively few outlier hospitals.

There are various surgical techniques used treat anal fistulas. The adoption and success rates of newer techniques have not been clearly established.The purpose of this study was to determine the healing rate after operations for anal fistulas in New England colorectal surgery practices.We conducted a retrospective review of a prospectively collected database.The study was conducted at colorectal surgery practices in New England.A prospective, multicenter registry was created by the New England Society of Colon and Rectal Surgeons. Surgeons were invited to collect data prospectively regarding patients operated on for anal fistulas between January 1, 2011, and August 1, 2013. Fistula classification, surgical intervention, continence scores, and healing were determined by the treating surgeon.Operation for anal fistula was performed.We measured the proportion of patients with healed fistulas at 3 months.Sixteen surgeons submitted data regarding 240 operations for fistula with curative intent. Mean patient age was 45 ± 14 years. A total of 158 patients (66%) were men, and 110 (46%) had undergone an anorectal operation. Twenty-nine (12%) had Crohn's disease. The healing rates of fistulotomy, advancement flap, and fistula plugs at 3 months were 94% (95% CI, 89-97), 60% (95% CI, 33-77), and 20% (95% CI, 5-50). The healing rate of the ligation of intersphincteric fistula tract procedure at 3 months was 79% (95% CI, 65-88). Hospital site was the only variable associated with healing (p0.05). Hospitals that performed more ligation of intersphincteric fistula tract procedures had higher healing rates at 3 months (p0.0001).This study was limited by selection bias and reporting bias.A wide variety of techniques are used to treat anal fistulas in our region. Fistulotomy continues to have excellent results. There has been enthusiastic early adoption of the ligation of intersphincteric fistula tract technique. Early healing rates after the ligation of intersphincteric fistula tract procedure appear to be excellent.

The rate of reoperation after transabdominal as compared with transperineal repair for rectal prolapse is unknown. We evaluated all patients who underwent surgical treatment for rectal prolapse performed through transabdominal or transperineal repair from the trackable California Inpatient data files and Revisit Analyses during the time period of January 1, 2005, through December 31, 2007. We specifically evaluated rates of reoperation and stoma formation during the 36-month study period. A total of 3400 patient discharges with rectal prolapse from California during the 36-month study period was identified. Of this cohort, 1772 patients had one or more prolapse repairs. Procedures were more likely to be performed through a transabdominal (1035 [58%]) as compared with a transperineal approach (737 [42%]). There was no difference in reoperation for transabdominal (11%) as compared with transperineal procedures (11%; P = 0.9). However, a significantly larger proportion of patients underwent stoma formation after transabdominal (8%) as compared with transperineal repair (5%; P < 0.02). Time to reoperation was not significantly different for patients treated with transabdominal (295 ± 254 days) as compared with transperineal repair (271 ± 246 days; P = 0.6). In conclusion, the risk of reoperation is substantial for both transabdominal and transperineal procedures for rectal prolapse.

There has been increased attention focused on reducing postoperative length of stay and mortality following colorectal surgery. We sought to identify adverse events associated with prolonged length of stay and mortality. We evaluated postoperative “adverse events,” prolonged length of stay, and mortality within 30 days of colorectal surgery in the National Surgical Quality Improvement Program (NSQIP) hospitals from January 2005 through December 2008. We then used multivariate models to establish the associations between adverse events and prolonged length of stay and mortality. A total of 54,237 patients underwent colorectal surgery: 39,980 (74 %) experienced no postoperative adverse events, while 14,257 (26 %) experienced one or more adverse events. Length of stay was prolonged (longer than 10 days) in 38 % of patients who experienced a postoperative adverse event and in 15 % of patients without events. Mortality increased with the number of postoperative adverse events. In multivariate models including preoperative comorbidity, patient risk factors, and adverse events, patients who experienced a cardiac arrest, septic shock, stroke, myocardial infarction, and/or renal failure were at highest odds of dying within 30 days of surgery. Patients with cardiac arrest, septic shock, stroke, myocardial infarction, and/or renal failure are at highest risk of mortality following colorectal surgery.

Purpose Preoperative short-course radiation therapy (SCRT) has rarely been used for rectal cancer in the United States, although 2 randomized phase 3 trials demonstrate equivalence to conventional chemoradiation (CRT), and recent updates to national guidelines include this regimen as a treatment option. We sought to evaluate the efficacy and safety of preoperative SCRT followed by immediate surgery within 1 week to treat rectal cancer in the US setting. Methods and materials All patients treated with preoperative SCRT (4 Gy × 5 fractions for total 20 Gy) followed by planned surgery within 1 week at our institution were retrospectively evaluated. Censored cases with ≥2 years of follow-up were included along with any disease failure or death. Patients with cM1 disease were excluded. Patients with yp stage II/III disease typically received adjuvant chemotherapy from the 1990s onwards. The primary outcomes were actuarial (Kaplan-Meier) 5-year locoregional control (LC), disease-free survival (DFS), and overall survival (OS) as well as late severe (greater than or equal to grade 3) toxicity. Results Our analysis included 202 consecutive patients with clinical stage I-III disease treated from 1977 through 2011. Median follow-up was 6.5 years (range, 2-29.2). Five-year disease outcomes were 95.9% ± 1.5% for LC, 76.4% ± 3.1% for DFS, and 84.6% ± 2.6% for OS. For patients with locally advanced rectal cancer (cT3-4 and/or cN+), 5-year LC, DFS, and OS were 95.1% ± 2.1%, 73.3% ± 4.3%, and 80.6% ± 3.7%, respectively. The late severe toxicity rate was 11.4%. Conclusions SCRT followed by immediate surgery is a safe and effective treatment for patients with rectal cancer in the United States. Though SCRT has not been widely adopted, recent updates to the national guidelines for rectal cancer as well as financial pressures to reduce healthcare costs may lead to increased utilization of this treatment regimen in the future.

Data comparing surgical outcomes following abdominal and transperineal approaches for rectal prolapse are limited.We sought to identify differences in postoperative complications following abdominal vs transperineal approaches to rectal prolapse.We studied a retrospective cohort in the American College of Surgeon's National Surgical Quality Improvement Program from January 2005 through December 2008.We identified all patients who underwent surgical treatment for rectal prolapse.We compared surgical outcomes of standard abdominal approaches compared with standard transperineal approaches to rectal prolapse.The primary outcomes measured were the validated morbidity outcomes and 30-day mortality.During the study period, 1485 patients underwent rectal prolapse surgery (706 abdominal and 779 transperineal). Patients treated with abdominal approaches had significantly higher rates of infectious (9.8% vs 3.7%) and overall (12.9% vs 7.6%) complications in comparison with those treated with transperineal approaches. On multivariate analysis, risk factors for overall complications were ASA class 4 (OR 6.4) and abdominal surgery (OR 2.3), whereas an albumin level of ≥ 2.5 was protective (OR 0.05). Significant predictors of infectious complications were ASA class 4 (OR 7.5), BMI25 (OR 1.8), and rectal prolapse surgery performed with an abdominal approach (OR 2.8).The retrospective design introduces potential selection bias.Abdominal surgery for rectal prolapse is a predictor of both infectious and overall complications. Patients with significant comorbidities or a high BMI are at particularly high risk for complications and may be better suited for a transperineal rather than abdominal approach for the treatment of rectal prolapse.

Aim We sought to identify the rate of re-operation after an index colorectal surgical procedure and potential contributing risk factors. Method This is a retrospective cohort study from the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients who either returned or did not return to the operating room after any colorectal resection from January 2005 to December 2008. Results From a total cohort of 635 265 patients included in the National Surgical Quality Improvement Program over the 4-year study period, we identified 54 237 patients who underwent colorectal operations. A return to the operating room was coded in 5.4 ± 0.1% of non colorectal resection patients and 7.6 ± 0.2% of colorectal resection patients (P

Geographic variability in the use of restorative proctectomy for rectal cancer has been described throughout the United States. We examined factors associated with high rates of colostomy formation after proctectomy for rectal cancer across US counties.We used state hospital discharge data from 21 states to determine county rates of restorative proctectomy vs nonrestorative proctectomy (ie, colostomy) for rectal cancer. We merged the county-level data with 1) tumor characteristics from Surveillance Epidemiology and End Results data; 2) number of specialty surgeons in the American Society of Colon and Rectal Surgeons and Society of Surgical Oncology; 3) county socioeconomic variables from census data; 4) colorectal cancer-screening rates from Medicare; and 5) hospital characteristics from the American Hospital Association. We then determined factors associated with high rates of colostomy formation (60%) after proctectomy for rectal cancer across counties.From January 1, 2002, to December 31, 2004, a total of 19,912 proctectomies were performed for cancer in 1050 counties, of which 489 had adequate sample size for evaluation. Based on county of residence information, nonrestorative proctectomy with colostomy was performed in greater than 60% of all patients with rectal cancer in 26% (n = 125) of counties. On multivariate analysis, more specialty surgeons (OR = 0.70; CI = 0.51-0.96) were protective against colostomy formation at the county level.The use of restorative techniques in rectal cancer surgery varies based on access to specialty colorectal cancer surgeons. Population-based directives are needed to standardize care for rectal cancer across the United States.

PURPOSE: This study was designed to compare short-term outcomes of laparoscopic vs. open total abdominal colectomy and end ileostomy for severe ulcerative colitis and to evaluate the impact of the initial surgical approach on subsequent operations for three-stage restorative proctocolectomy. METHODS: Perioperative demographic and outcome data for patients with severe ulcerative colitis who underwent laparoscopic (n = 37) or open (n = 41) total abdominal colectomy at the initial stage of a three-stage restorative proctocolectomy were compared. Each stage was analyzed independently by using two-tailed t-tests and analysis of covariance. RESULTS: Patients who underwent laparoscopic total abdominal colectomy had higher serum albumin (P = 0.0003), less inpatient narcotic usage (P = 0.0143), faster return of bowel function (P = 0.0001), and shorter length of stay (P = 0.039). There were no differences in perioperative parameters for the restorative proctectomy and ileostomy closure. The laparoscopic total abdominal colectomy patients underwent subsequent restorative proctectomy 49 days sooner (P = 0.0044) and ileostomy closure 17 days sooner (P = 0.00003) than the open total abdominal colectomy patients. CONCLUSIONS: Laparoscopic abdominal colectomy for severe ulcerative colitis in selected patients is safe and is associated with short-term benefits that may lead to faster recovery and progression to completion of restorative proctocolectomy.

Objective To identify the factors that affect the disease-free survival (DFS) of rectal cancer patients. Method Patients from an IRB approved rectal cancer database were reviewed (1990–2000). All patients underwent either abdominoperineal resection or low anterior resection using total mesorectal excision with curative intent. Univariate and multivariate analyses were performed to analyse the factors that influenced DFS. Results A total of 304 patients were reviewed (mean age 64, 52% male). Seventy-seven per cent of patients received neoadjuvant therapy (28.6% short-course radiation therapy (RT), 35.5% long-course RT, 12.5% chemo-RT). The radial margin was involved with tumour in 5.2% of patients (final pathology). The overall survival rate was 85.2% with a mean follow-up time of 33 ± 26 months. The mean time to death was 34.8 ± 26.8 months. Local recurrence (± distant recurrence) occurred in 4%. Anastomotic leaks occurred in 3.6% of patients. Overall pathologic stage, pathologic T stage, nodal status, the use of adjuvant chemotherapy, tumour fixation, involvement of the radial margin, the presence of mucin, and lymphatic and perineural invasion (PNI) were predictors of DFS by univariate analysis. Of note, anastomotic leaks and obstructing cancers did not influence DFS. Using multivariate analysis with backward elimination, overall pathologic stage, radial margin status, adjuvant chemotherapy, and PNI predicted the DFS. Conclusion Major predictors of DFS in rectal cancer are the overall pathologic stage, adjuvant chemotherapy, radial margin status and PNI. Radial margin status may be a marker of tumour aggressiveness and should be considered in deciding on adjuvant chemotherapy.

During the past 15 years, there has been increasing enthusiasm for the use of laparoscopic techniques in the operative treatment of patients suffering from colorectal disease. Laparoscopic colectomy has been demonstrated to be safe for patients suffering from adenocarcinoma of the intraperitoneal colon. Attention is now being focused on the treatment of patients with rectal adenocarcinoma using laparoscopic methods. Prospective data analysis will be crucial in determining whether laparoscopic proctectomy provides equivalent results to open procedures.

Because of the natural aversion to the anus, patients and physicians often ascribe virtually any anorectal symptom to "hemorrhoids" without an adequate investigation of other potential causes. This practice may delay appropriate care for other benign anorectal diseases, or worse, delay treatment of a missed malignancy. However, many patients truly suffer from symptomatic hemorrhoids. Although hemorrhoids are normal anatomic structures, they may enlarge, prolapse, bleed, or thrombose. The diagnosis can be made by history, physical examination, anoscopy and/or proctoscopy. Internal hemorrhoids are classified by their degree of prolapse.

Evidence about the efficacy of laparoscopic resection of rectal cancer is incomplete, particularly for patients with more advanced-stage disease.To determine whether laparoscopic resection is noninferior to open resection, as determined by gross pathologic and histologic evaluation of the resected proctectomy specimen.A multicenter, balanced, noninferiority, randomized trial enrolled patients between October 2008 and September 2013. The trial was conducted by credentialed surgeons from 35 institutions in the United States and Canada. A total of 486 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge were randomized after completion of neoadjuvant therapy to laparoscopic or open resection.Standard laparoscopic and open approaches were performed by the credentialed surgeons.The primary outcome assessing efficacy was a composite of circumferential radial margin greater than 1 mm, distal margin without tumor, and completeness of total mesorectal excision. A 6% noninferiority margin was chosen according to clinical relevance estimation.Two hundred forty patients with laparoscopic resection and 222 with open resection were evaluable for analysis of the 486 enrolled. Successful resection occurred in 81.7% of laparoscopic resection cases (95% CI, 76.8%-86.6%) and 86.9% of open resection cases (95% CI, 82.5%-91.4%) and did not support noninferiority (difference, -5.3%; 1-sided 95% CI, -10.8% to ∞; P for noninferiority = .41). Patients underwent low anterior resection (76.7%) or abdominoperineal resection (23.3%). Conversion to open resection occurred in 11.3% of patients. Operative time was significantly longer for laparoscopic resection (mean, 266.2 vs 220.6 minutes; mean difference, 45.5 minutes; 95% CI, 27.7-63.4; P .001). Length of stay (7.3 vs 7.0 days; mean difference, 0.3 days; 95% CI, -0.6 to 1.1), readmission within 30 days (3.3% vs 4.1%; difference, -0.7%; 95% CI, -4.2% to 2.7%), and severe complications (22.5% vs 22.1%; difference, 0.4%; 95% CI, -4.2% to 2.7%) did not differ significantly. Quality of the total mesorectal excision specimen in 462 operated and analyzed surgeries was complete (77%) and nearly complete (16.5%) in 93.5% of the cases. Negative circumferential radial margin was observed in 90% of the overall group (87.9% laparoscopic resection and 92.3% open resection; P = .11). Distal margin result was negative in more than 98% of patients irrespective of type of surgery (P = .91).Among patients with stage II or III rectal cancer, the use of laparoscopic resection compared with open resection failed to meet the criterion for noninferiority for pathologic outcomes. Pending clinical oncologic outcomes, the findings do not support the use of laparoscopic resection in these patients.clinicaltrials.gov Identifier: NCT00726622.

Background We sought to determine the differential role of patient safety indicator (PSI) events on mortality after weekend as compared with weekday admission. Materials and methods We evaluated Agency for Healthcare Research and Quality PSI events within a cohort of patients with nonelective admissions. First, we identified all patients with a PSI based on day of admission (weekend versus weekday). Then, we evaluated the outcome of mortality after each PSI event. Finally, we entered age, sex, race, median household income, payer information, and Charlson comorbidity scores in regression models to develop risk ratios of weekend to weekday PSI events and mortality. Results There were 28,236,749 patients evaluated with 428,685 (1.5%) experiencing one or more PSI events. The rate of PSI was the same for patients admitted on weekends as compared to weekdays (1.5%). However, the risk of mortality was 7% higher if a PSI event occurred to a patient admitted on a weekend as compared with a weekday. In addition, compared to patients admitted on weekdays, patients admitted on weekends had a 36% higher risk of postoperative wound dehiscence, 19% greater risk of death in a low-mortality diagnostic-related group, 19% increased risk of postoperative hip fracture, and 8% elevated risk of surgical inpatient death. Conclusions Risk adjusted data reveal that PSI events are substantially higher among patients admitted on weekends. The considerable differences in death after PSI events in patients admitted on weekends as compared with weekdays indicate that responses to adverse events may be less effective on weekends.

Operative results of volvulus are largely unknown because of infrequent diagnosis.We examined the results of operative intervention for colonic volvulus.We merged trackable data from the California Inpatient Database with Supplemental Files for Revisit Analyses between January 1, 2005, and December 31, 2007.Trackable data from California discharge records.We identified all of the patients with colonic volvulus who underwent 1 of 4 surgical procedures, including manipulation/fixation of the colon, right colectomy, left colectomy, or total colectomy.During the 36-month study period, we identified recurrence risk, recurrence requiring reoperation, time to reoperation, stoma formation, disposition on discharge, and in-hospital mortality. Fisher exact, χ(2), and ANOVA tests were used when appropriate.We identified 2141 patients with colonic volvulus who were undergoing intraoperative manipulation/fixation of the colon (n = 209 (12%)), right (n = 728 (41%)), left (n = 781 (44%)), or total colectomy (n = 56 (3%)). Patients treated with intraoperative manipulation/fixation were younger, more likely to be women, and more likely to have private insurance. Patients who underwent total colectomy had the highest risk of mortality (21%), highest risk of stoma creation (64%), and longest length of stay (18 days); were more likely to be readmitted (9%); and were the most likely to be discharged to a skilled nursing facility (48%). Patients treated with intraoperative manipulation/fixation had the lowest mortality, risk of stoma formation, length of stay, and likelihood of discharge to skilled nursing facility but the highest risk of subsequent procedures for volvulus (26%) over a follow-up ranging from 0 to 687 days.This study was limited by retrospective study design, heterogeneous patient factors, and inability to identify the time of last follow-up.The majority of patients with volvulus underwent a resectional procedure. A subset without resection had favorable initial outcomes but remained at high risk for subsequent procedures. There may be a potential role for evaluating intraoperative manipulation/fixation in a small subset of patients with colonic volvulus.

With the increasing popularity of minimally invasive approaches to surgery, laparoscopic techniques are being applied increasingly to more complex procedures. Surgeons who are interested in gaining skill and confidence with the techniques of rectal mobilization and resection initially should consider attempting procedures for benign disease. Patients who have rectal prolapse, who often have wide, accommodating pelvic anatomy, are the logical choice with whom to begin the laparoscopic rectal experience. Laparoscopic restorative proctocolectomy is more technically challenging. Laparoscopic proctectomy for rectal cancer probably should remain in the hands of well-trained, high-volume, experienced surgeons who have built a dedicated team for treatment of these patients, and who track their outcomes prospectively.

In dieser Studie sollten die Wirksamkeit von Sentinel-Lymph-Node-Mapping bei Patienten mit intraperitonealem Kolonkarzinom bestimmt und ein Algorithmus zur Vorhersage eines moglichen Uberlebensvorteils unter Verwendung Sentinel-Node-Mapping und Lymphknoten-Ultrauntersuchungstechniken favorisierender Best-Case-Einschatzungen entwickelt werden. 41 Patienten mit intraperitonealem Kolonkarzinom, die sich einer Kolektomie mit kurativer Zielsetzung unterzogen, wurden prospektiv untersucht. Nach Mobilisation von Kolon und Mesenterium wurden 1–2 ml des Farbstoffs Isosulfanblau subseros um den Tumor herum injiziert. Die ersten blaugefarbten Lymphknoten wurden als Sentinel Nodes (Wachterknoten) identifiziert. Weitere Knoten wurden vom Pathologen routinemasig durch manuelle Praparation des Mesenteriums erkannt. Alle Knoten wurden routinemasig durch histologische Untersuchung mittels Hamatoxylin-Eosin-Farbung aufgearbeitet. Um einen Algorithmus zur Vorhersage des moglichen Uberlebensvorteils durch Sentinel-Node-Mapping und Lymphknoten-Ultrauntersuchungstechniken zu entwickeln, wurden Annahmen auf der Basis von Literaturdaten postuliert. Jede Tendenz war auf den Erfolg der Techniken gerichtet. Drei von 41 Patienten (7%) wurde keine Farbe injiziert, und sie wurden von der weiteren Analyse ausgeschlossen. Das Krankheitsstadium der ubrigen 38 Patienten verteilte sich wie folgt: Stadium I: n = 10 (26%); Stadium II: n = 15 (39%); Stadium III: n = 11 (29%); Stadium IV: n = 2 (5%). Mindestens ein Sentinel Node wurde bei 30 von 38 Patienten (79%) identifiziert. Die mittlere Anzahl erkannter Wachterknoten lag bei zwei (Streuung ein bis drei). Die mittlere insgesamt gewonnene Anzahl an Lymphknoten betrug 14 (Streuung sieben bis 45). Bei 26 von 38 Patienten (68%) waren alle Knoten negativ. Sentinel Nodes und Nonsentinel Nodes waren bei zwei von 38 Patienten (5%) positiv. Bei einem von 38 Patienten (3%) waren Sentinel Nodes die einzigen positiven Lymphknoten. Bei neun von 38 Patienten (24%) waren Sentinel Nodes negativ und Nonsentinel Nodes positiv. Folglich ware Sentinel-Node-Mapping nur fur 3% moglicherweise von Nutzen gewesen, versagte aber in 24% der Patienten unserer Untersuchung bei der genauen Erkennung von Lymphknotenmetastasen. Um einen Algorithmus zur Berechnung des Uberlebensvorteils zu entwickeln, trafen wir folgende Annahmen: Kombination des Krankheitsstadiums I und II (0,5); Anteil des Materials, bei dem durch Anwendung histologischer Untersuchung mittels Hamatoxylin-Eosin-Farbung das Stadium zu niedrig eingestuft worden war und das bei differenzierterer Analyse verborgene positive Knoten enthalten konnte (0,15); Anteil von okkulten positiven Knoten, die durch Sentinel-Node-Mapping entdeckt wurden (0,9); sowie Uberlebensvorteil durch Chemotherapie (0,33). Somit lage der Anteil der Patienten, die von Sentinel-Lymph-Node-Mapping und Lymphknoten-Ultrauntersuchungstechniken profitierten, bei 0,02 (2%). Sentinel-Node-Mapping mit Isosulfanblau-Farbung und Routineaufarbeitung entnommener Knoten verbessert die Genauigkeit des Stagings bei Patienten mit intraperitonealem Kolonkarzinom nicht. Sogar bei Anwendung von Best-Case-Annahmen ist der Prozentsatz von Patienten, die moglicherweise vom Sentinel-Lymph-Node-Mapping profitieren konnten, klein.

The adoption of laparoscopic proctectomy for rectal cancer has been relatively slow, primarily because of the technical difficulty of the procedure. The wide surgeon-to-surgeon variability in disease-free survival and local pelvic recurrence noted after open proctectomy is probably due to differences in surgical technique, and these differences are likely to be magnified when the additional challenge of laparoscopy is added to the procedure. At present, oncologic outcomes data are sparse. However, given that the theoretic concerns regarding laparoscopic colectomy for colon cancer are likely to be allayed as data from large prospective trials become mature, the adoption of laparoscopic techniques to perform curative proctectomy will occur as technical challenges are overcome and experience and training improve.

To compare the outcome from preoperative chemoradiation (CXRT) and from radiation therapy (RT) in the treatment of rectal cancer in two large, single-institutional experiences.Between 1978 and 1995, 403 patients with localized, nonmetastatic, clinically staged T3 or T4 rectal cancer patients were treated with preoperative RT alone at two institutions. Patients at institution 1 (n = 207) were treated with pelvic CXRT exclusively, and patients at institution 2 were treated (except for 8 given CXRT) with pelvic RT alone (n = 196). In addition, a third group (n = 61) was treated with CXRT at institution 2 between 1998 and 2000 after a policy change. Both institutions delivered 45 Gy in five fractions as a standard dose, but institution 2 used 20 Gy in five fractions in selected cases (n = 26). At both institutions, concurrent chemotherapy consisted of a continuous infusion of 5-fluorouracil (5-FU) at a dosage of 1500 mg/m(2)/week. The end points were response, sphincter preservation (SP), relapse-free survival (RFS), pelvic disease control (PC), and overall survival (OS).Median follow-up was 63 months for all living patients at institution 1 and in the primary group of institution 2. Multivariate analysis of the patients in these groups showed that the use of concurrent chemotherapy improved tumor response (T-stage downstaging, 62% vs. 42%, p = 0.001, and pathologic complete response, 23% vs. 5% p0.0001), but did not significantly improve LC, RFS, or OS. Follow-up for the secondary group at institution 2 was insufficient to allow the analysis of these endpoints. In the subset of patients receiving 45 Gy who had rectal tumorsor /=6 cm from the anal verge (institution 1: n = 132; institution 2 primary: n = 79; institution 2 secondary: n = 33), there was a significant improvement in SP with the use of concurrent chemotherapy (39% at institution 1 compared with 13% in the primary group at institution 2, p0.0001). A logistic regression analysis of clinical prognostic factors indicated that the use of concurrent chemotherapy independently influenced SP in these low tumors (p = 0.002). This finding was supported by a 36% SP rate in the secondary group at institution 2. Thus SP increased after the addition of chemotherapy at institution 2.The use of concurrent 5-FU with preoperative radiation therapy for T3 and T4 rectal cancer independently increases tumor response and may contribute to increased SP in patients with low rectal cancer.

The aim of this retrospective, case-matched controlled study was to determine the benefit of laparoscopic-assisted colectomy (LC) for the elderly (75 years of age) and the young (75 years of age) compared to an open colectomy (OC) control group.A retrospective review of 39 patients older than 75 years of age and 38 patients younger than 75 years of age who underwent LC for colorectal cancer between 1991 and 1999 was performed. LC patients were matched with an open control group for procedure, age, gender, year of procedure, and surgeon. Procedures included right and left colectomy, anterior resection of the rectosigmoid, and abdominoperineal resection. Measured intraoperative variables included anesthesia time, operative time, and estimated blood loss. Postoperative parameters consisted of duration of intravenous or epidural narcotic usage, return of bowel function (RBF), length of stay, and independence at discharge. These variables were compared in the entire group of 154 patients.Mean ages were 81.4 and 81.8 years for LC and OC age75 and 62.9 and 62.7 for LC and OC age75. Mean anesthesia time and operative time were significantly longer (p0.05) for LC compared to OC (46.8 vs 39.3 and 159.3 vs 111.7 min, respectively) for age75 and for age75 (47.1 vs 40.3 and 182.8 vs 135.5 min, respectively). LC achieved faster recovery in both age groups: RBF (3.9 vs 4.9 days for age75; 6.7 vs 7.7 days for age75) (p0.05). Narcotic usage was shorter for the LC group age75 (3.3 vs 4.4 days; p0.05). There was no significant difference in independence at discharge between LC and OC in either age group. Faster recovery was seen with left LC in age75 and right LC in age75 compared to OC.The advantages of LC over OC are the same for the elderly and the young. There may be a selective benefit of laparoscopic left colectomy in the elderly and laparoscopic right colectomy in the young.

Background. Wound infections are common and serious surgical complications. Wound perfusion delivers oxygen, inflammatory cells, growth factors, and cytokines to injured tissues. Hypoperfused regions experience low oxygen tensions that do not support adequate oxidative killing or wound healing. Clinicians may fail to recognize clinically important hypovolemia because hemodynamic stability and urine output are maintained after peripheral perfusion is compromised. We tested the hypothesis that supplemental fluid administration during and after elective colon resection increases tissue perfusion and tissue oxygen pressure. Methods. Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mL·kg−1·h−1, n = 26) or aggressive (16 to 18 mL·kg−1·h−1, n = 30) fluid management. Anesthetic technique was standardized. We used 60% nitrous oxide in 40% oxygen. During surgery and postanesthetic recovery, subcutaneous oxygen tension (PsqO2) was measured by using a polarographic sensor implanted subcutaneously into 1 upper arm. Capillary blood flow was evaluated postoperatively with a thermal diffusion system. Data were analyzed with 2-tailed t tests; P value less than.05 was considered statistically significant. Results. Hemodynamic and renal responses were similar in the groups. Intraoperative tissue oxygen tension was significantly greater in patients given supplemental fluid: 81 ± 26 vs 67 ± 18 mm Hg, P =.03. Postoperative PsqO2 (77 ± 26 vs 59 ± 15 mm Hg, P =.009) and capillary blood flow (69 ± 12 vs 53 ± 12, P

BACKGROUND: There is wide variability in reported locoregional recurrence rates after curative resection of adenocarcinoma of the intraperitoneal colon, and there is no universally accepted surgical technique regarding length of the resected specimen or extent of lymphadenectomy. The aim of this study was to determine the disease-free survival, locoregional failure, and perioperative morbidity of patients undergoing curative resection of colon adenocarcinoma. STUDY DESIGN: The records of 316 consecutive patients undergoing curative resection for primary adenocarcinoma of the intraperitoneal colon between 1990 and 1995 were reviewed. Locoregional recurrence was defined as disease at the anastomosis or in the adjacent mesentery, peritoneum, retroperitoneum, or carcinomatosis. The product-limit method (Kaplan-Meier) was used to analyze survival and tumor recurrence. RESULTS: The study population comprised 167 men and 149 women, mean age 70 ± 12 years (range 22 to 95 years). Median followup was 63 ± 25 months. Five-year disease-free survival was 84% overall. Disease-free survival paralleled tumor stage: stage I, 99% (n = 73); stage II, 87% (n = 151); stage III, 72% (n = 92). The predominant pattern of tumor recurrence was distant failure only. Overall locoregional recurrence (locoregional and locoregional plus distant) at 5 years was 4%. Locoregional recurrence paralleled tumor stage: stage I, 0%; stage II, 2%; stage III, 10%. Of the 12 patients who suffered locoregional recurrence, 9 (75%) had T4 primary tumors, N2 nodal disease, or both. Major and minor complications occurred in 93 patients (29%) including: anastomotic leak or intraabdominal abscess (n = 4, 1%); hemorrhage (n = 8, 3%); cardiac complications (n = 17, 5%); pulmonary embolism (n = 4, 1%); death (n = 2, 1%). Multivariate analysis (Cox proportional hazards) revealed that the only independent predictor of disease-free survival and locoregional control was tumor stage. CONCLUSION: Longterm survival and locoregional control can be achieved for patients with colon cancer, with low morbidity. In the absence of adjacent organ invasion and N2 nodal disease, locoregional recurrence should be a rare event. Just as for rectal cancer, the technical aspects of colectomy for colon cancer deserve renewed attention.

Background There is an accelerated effort to reduce hospital readmissions despite minimal data detailing risk factors associated with this outcome. Materials and methods We analyzed National Surgical Quality Improvement Project data from January 1, 2011–December 31, 2011, evaluating all patients undergoing one of 34 targeted operative procedures across all surgical specialties. Multivariate regression models of risk for readmission were developed including targeted procedure codes, demographic variables, preoperative variables, intraoperative variables, and postoperative adverse events. Our main outcome measure was hospital readmission. Results A total of 217, 389 patients met study inclusion criteria. Minimal associations existed between patient factors and risk of readmission. Adverse events including unplanned operating room return (odds ratio [OR] 8.5; confidence interval [CI] 8.0–9.0), pulmonary embolism (OR 8.2; CI 7.1–9.6), deep incisional infection (OR 7.5; CI 6.7–8.5), and organ space infection (OR 5.8; CI 5.3–6.3) were associated with increased risk of readmission. Our data suggest the type of procedure performed is significantly associated with risk of readmission. Furthermore, multivariate analysis revealed procedures, involving the pancreas, rectum, bladder, and lower extremity vascular bypass, were associated with the highest risk of readmission. Conclusions Postoperative complications demonstrated stronger association with readmission than patient factors. Focused analysis of higher risk procedures may provide insight into strategies for risk reduction.

The objective of this study was to identify clinical leak in diverted colorectal anastomoses. Cohort analysis. The study was conducted in a subspecialty practice at a tertiary care facility. Consecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between July 16, 2007 and June, 31 2012. No intervention was applied. Clinical anastomotic leak. Two hundred forty-five patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 34 (14 %) clinical leaks were identified at a median of 43 days. Clinical leaks were identified in 13 (5 %) patients within 30 days of surgery (early leaks) and in 21 (9 %) patients after 30 days of surgery (late leaks). Age, sex, use of neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no evidence of leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease or other diagnoses, i.e., radiation enteritis, ischemia, and injury/enterotomy. Patients with clinical leak were not more likely to have air leaks on intraoperative air leak testing. In diverted anastomoses, most leaks become clinically apparent beyond 30 days. The standard practice of censoring outcomes that occur beyond postoperative day 30 will fail to identify a substantial fraction of leaks in diverted colorectal anastomoses.

Purpose Endocavitary radiation (RT) provides a conservative alternative to proctectomy. Although most suitable for small, mobile lesions, patients with less favorable tumors are often referred if they are poor surgical candidates. Knowing the extent to which radiation can control such tumors can be an important factor in making clinical decisions. Methods and materials One hundred ninety-nine patients, who received endocavitary RT with or without external beam RT (EBRT) during 1981 through 1995, were followed for disease status for a median of 70 months, including deaths from intercurrent causes. In the early years of the study, 21 patients were treated with endocavitary RT alone, the remainder of the patients received pelvic EBRT (usually 45 Gy in 25 fractions) 5-7 weeks before endocavitary RT. Results Overall, 141 patients (71%) had local control with RT alone. Salvage surgery rendered an additional 20 patients disease free, for an ultimate local control rate of 81%. On multivariate analysis for local control (excluding surgical salvage), the most significant factors were mobility to palpation, use of EBRT, and whether pretreatment debulking of all macroscopic disease had been done (generally a piecemeal, nontransmural procedure). Of 77 cases staged by transrectal ultrasonography, the local control rate with RT alone was 100% for uT1 lesions, 85% (90% with no evidence of disease after salvage) for freely mobile uT2 lesions, and 56% (67% with no evidence of disease after salvage) for uT3 lesions and uT2 lesions that were not freely mobile. Conclusions Patients with small mobile tumors that are either uT1 or have only a scar after debulking achieve excellent local control with endocavitary RT. About 15% of mobile uT2 tumors fail RT; therefore, careful follow-up is critical. Small uT3 tumors are appropriate for this treatment only if substantial contraindications to proctectomy are present.

In recent years, treatment with combined chemotherapy and radiation has become the standard of care for epidermoid carcinoma of the anus. However, optimal radiotherapy techniques and doses are not well established.During the period 1975-1997, 106 patients with epidermoid carcinoma of the anal canal underwent radiation therapy. Treatment policies evolved from radiation therapy alone or with surgery, to combined chemotherapy and radiation followed by surgery, to combined chemotherapy and radiation.Overall 74% of patients were NED (no evidence of disease) at last follow-up. The most important clinical correlate with ultimate freedom from disease (includes the contribution of salvage surgery) was extent of disease. The 5-year ultimate freedom from disease was 87+/-5% for T1/T2N0, 78+/-10% for T3N0 (15% salvaged by surgery), and 43+/-10% for either T4N0 or any N+ lesions (P0.001, Tarone-Ware). There was no difference between planned vs. expectant surgery (5-year ultimate NED: 67+/-11% planned surgery vs. 73+/-5% expectant surgery). The most important correlate with late toxicity was a history of major pelvic surgery (surgical vs. non-surgical group: P=0.013, Fisher's exact test, two-tailed summation). Thirty-three additional malignancies have been seen in 26 patients. The most common additional malignancies were gynecologic (nine cases), head and neck (six cases), and lung cancer (five cases).For T1/T2N0 disease, moderate doses of radiation combined with chemotherapy provided adequate treatment. T4N0 and N+ lesions are the most appropriate candidates for investigational protocols evaluating dose intensification. T3N0 tumors may also be appropriate for investigation; however, dose intensification may ultimately prove counterproductive if the cure rate is not improved and salvage surgery is rendered more difficult. The volume of irradiated small bowel should be minimized for patients who have a past history of major pelvic surgery or who (because of locally advanced tumors) may need salvage surgery in the future. Because of the occurrence of additional malignancy, patients with anal cancer should receive general oncologic screening in long-term follow-up.

Improving the response to preoperative therapy may increase the likelihood of successful resection of locally advanced rectal cancers. Historically, the pathologic complete response (pCR) rate has beenapproximately 10% with preoperative radiation therapy alone andapproximately 20% with concurrent chemotherapy and radiation therapy.Thirty-seven patients were enrolled on a prospective Phase I/II protocol conducted jointly at Washington University, St. Louis and the Catholic University of the Sacred Heart, Rome evaluating a three-dimensionally (3D) planned boost as part of the preoperative treatment of patients with unresectable or recurrent rectal cancer. Preoperative treatment consisted of 4500 cGy in 25 fractions over 5 weeks to the pelvis, with a 3D planned 90 cGy per fraction boost delivered once or twice a week concurrently (no time delay) with the pelvic radiation. Thus, on days when the boost was treated, the tumor received a dose of 270 cGy in one fraction while the remainder of the pelvis received 180 cGy. When indicated, nonaxial beams were used for the boost. The boost treatment was twice a week (total boost dose 900 cGy) if small bowel could be excluded from the boost volume, otherwise the boost was delivered once a week (total boost dose 450 cGy). Patients also received continuous infusion of 5-fluorouracil (1500 mg/m(2)-week) concurrently with the radiation as well as postoperative 5-FU/leucovorin.All 37 patients completed preoperative radiotherapy as planned within 32--39 elapsed days. Twenty-seven underwent proctectomy; reasons for unresectability included persistent locally advanced disease (6 cases) and progressive distant metastatic disease with stable or smaller local disease (4 cases). Actuarial 3-year survival was 82% for the group as a whole. Among resected cases the 3-year local control and freedom from disease relapse were 86% and 69%, respectively.Twenty-four of the lesions (65%) achieved an objective clinical response by size criteria, including 9 (24%) with pCR at the primary site (documented T0 at surgery). The most important factor for pCR was tumor volume: small lesions with planning target volume (PTV)200 cc showed a 50% pCR rate (p = 0.02). There were no treatment associated fatalities. Nine of the 37 patients (24%) experienced Grade 3 or 4 toxicities (usually proctitis) during preoperative treatment. There were an additional 7 perioperative and 2 late toxicities. The most important factors for small bowel toxicity (acute or late) were small bowel volume (or = 150 cc at doses exceeding 4000 cGy) and large tumor (PTVor = 800 cc). For rectal toxicity the threshold is PTVor = 500 cc.3D planned boost therapy is feasible. In addition to permitting the use of nonaxial beams for improved dose distributions, 3D planning provides tumor and normal tissue dose-volume information that is important in interpreting outcome. Every effort should be made to limit the treated small bowel to less than 150 cc. Tumor size is the most important predictor of response, with small lesions of PTV200 cc most likely to develop complete responses.