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L’incidence de l’appendicite aigue est estimee a 75 cas par 100 000 personnes annuellement, et elle est la plus elevee chez les patients de 10–19 ans[1][1]. Globalement, 67 % des cas sont des appendicites non perforees[1][1]. Selon les conclusions de recents essais randomises et contr

In 2009, a Rapid Access Breast Clinic (rabc) was opened at our urban hospital. Compared with the traditional system (ts), the navigated care through the clinic was associated with a significantly shorter time to surgical consultation. Since 2009, many radiology facilities have introduced facilitated-care pathways for patients with breast pathology. Our objective was to determine if that change in diagnostic imaging pathways had eliminated the advantage in time to care previously shown for the rabc. All patients seen in the rabc and the office-based ts in November&ndash, December 2012 were included in the analysis. A retrospective chart review tabulated demographic, surgeon, pathology, and radiologic data, including time intervals to care for all patients. The results were compared with data from 2009. In 2012, time from presentation to surgical consultation was less for the rabc group than for the ts group (36 days vs. 73 days, p < 0.001) for both malignant (31 days vs. 55 days, p = 0.008) and benign diagnoses (43 days vs. 79 days, p < 0.001). Comparing the 2012 results with results from 2009, a decline in mean wait time was observed for the ts group (86 days vs. 73 days, p = 0.02). Compared with patients having investigations in the ts, rabc patients with cancer were more likely to undergo surgery within 60 days of presentation (33% vs. 15%, p = 0.04). The coordination of radiology and clinical care reduces wait times for diagnosis and surgery in breast cancer. To achieve recommended targets, we recommend implementation of more systematic coordination of care for a breast cancer diagnosis and of navigation to surgeons for patients needing surgical care.

ERUS and MRI are used for preoperative imaging of rectal cancer. Here, we compare ERUS and MRI for accuracy of CRM prediction at mid- and distal rectal locations. In retrospective review, 20 rectal cancer patients having TME surgery had both ERUS and MRI preoperatively: 8 mid rectum and 12 in distal rectum. Predicted CRM by ERUS and MRI were compared to TME pathology. Overall, predicted CRM was 6.5 ± 3.6 mm by ERUS, 7.7 ± 5.0 mm by MRI, and 6.0 ± 4.6 mm by pathology. Overall, correlation coefficients to pathology were 0.77 (p = 0.0004) for ERUS and 0.64 (p = 0.008) for MRI. In distal rectum, correlation coefficients were 0.71 (p = 0.02) for ERUS and −0.10 (p = 0.79) for MRI. In mid rectum, correlation coefficients were 0.92 (p = 0.01) for ERUS and 0.44 (p = 0.38) for MRI. While MRI is used routinely for preoperative rectal cancer imaging, ERUS can provide additional assessment of CRM for mid or distal rectal lesions. Further investigation is needed to support these preliminary ERUS CRM findings in mid and distal rectum.

Background The relationship between hospital volume and patient outcomes remains controversial for rectal cancer. Methods This is a population-based database study. Patients treated with surgery for a stage I to III rectal adenocarcinoma from 2003 to 2009 were identified. High-volume hospitals (HVH) were those centers performing 20 surgeries or more per year. Primary outcomes were operative and perioperative factors that have proven influence on patient outcomes. Results In all, 2,081 patients had surgery for rectal cancer. Of these, 1,690 patients had surgery in an HVH and 391 had surgery in a low-volume hospital. On multivariate analysis, patients who had surgery in an HVH were more likely to have sphincter-preserving surgery, 12 or more lymph nodes removed with the tumor, neoadjuvant radiation therapy, and receive pre-operative or postoperative chemotherapy. Conclusions For rectal cancer patients in British Columbia, Canada, being treated at an HVH is associated with several quality indicators linked to better patient outcomes.

Purpose – The purpose of this chapter is to assess the avenues through which traditional notions of information literacy skills shape oral communication curriculum and to identify steps that can be taken to transform the experience of students in the public speaking classroom so that they are offered an opportunity to develop understandings of how they use information to learn.Approach – This chapter engages in an analysis of teaching materials and best practice scholarship used in the traditional college public speaking classroom. An informed learning perspective is applied to this corpus to identify the ways in which an information literacy skills approach is reflected in current practice.Findings – The analysis highlights the prevalence of an information literacy skills approach throughout the oral communication curriculum. Textbooks, assignment types and guidelines, along with grading rubrics and instructor feedback all perpetuate a skills approach. Outside class support, including peer tutors and library instruction, also contribute to a focus on information literacy over informed learning.Implications – Informed learners are better prepared to engage and apply information across contexts and to use information to continue learning. Informed learners are reflective on the knowledge they gain through information use. Therefore, this chapter concludes that public speaking courses, along with the communication centers and libraries that support oral communication instruction, should embrace an informed learning approach to the development of course materials, assignments, and teaching.Originality/value – Suggestions for reframing public speaking curriculum and support from the informed learning perspective are provided.

Summary Background In non-surgical settings, covert stroke is more common than overt stroke and is associated with cognitive decline. Although overt stroke occurs in less than 1% of adults after non-cardiac surgery and is associated with substantial morbidity, we know little about perioperative covert stroke. Therefore, our primary aim was to investigate the relationship between perioperative covert stroke (ie, an acute brain infarct detected on an MRI after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive decline 1 year after surgery. Methods NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries, in which we assessed patients aged 65 years or older who underwent inpatient, elective, non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology experts, masked to clinical data, assessed each MRI for acute brain infarction. Using multivariable regression, we explored the association between covert stroke and the primary outcome of cognitive decline, defined as a decrease of 2 points or more on the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up. Patients, health-care providers, and outcome adjudicators were masked to MRI results. Findings Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study, 78 (7%; 95% CI 6–9) had a perioperative covert stroke. Among the patients who completed the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%) of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22–3·20, absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06–4·73, absolute risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year follow-up (HR 4·13, 1·14–14·99, absolute risk increase 3%; p=0·019). Interpretation Perioperative covert stroke is associated with an increased risk of cognitive decline 1 year after non-cardiac surgery, and perioperative covert stroke occurred in one in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is needed to establish prevention and management strategies for perioperative covert stroke. Funding Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and Medical Research Fund, Government of the Hong Kong Special Administrative Region, China; and The Neurological Foundation of New Zealand.

Aims Completeness of procedure reports is an important quality indicator in endoscopy. A dictation template was developed to ensure key elements were included in colonoscopy and esophagogastroduodenoscopy (EGD) reports. Endoscopy reports were reviewed prior to and following implementation of the dictation templates to determine whether report completeness improved. Methods Key elements in an endoscopic report were identified from published guidelines and posted at dictation stations. Colonoscopy and EGD reports were reviewed for the nine physicians performing endoscopy at St. Paul’s Hospital prior to and following implementation of dictation templates. Dictation completeness was defined as inclusion of all key elements. Dictation completeness and inclusion of individual key elements at the two time points were compared using the t-test and Chi-square test. Results Reports for 4648 procedures undertaken by nine endoscopists were reviewed for completeness at each time point (2008 and 2014). Colonoscopy report completeness increased from 65.8% to 83.2% (P < 0.001). Items that improved included documentation of consent, endoscope used, complications, withdrawal time and rectal retroflexion. EGD report completeness increased from 72.7% to 77.3% (P < 0.001) with improvement in documentation of consent and complications. Items consistently underreported for colonoscopy and EGD at both time points included: patient age, comorbidities, current medications and patient comfort. Conclusion There was an association between the use of a posted dictation template at dictation stations and the improved completeness of endoscopic reports.

Transanal endoscopic surgery is the treatment of choice in patients with rectal adenomas that cannot be removed by endoscopy. However, the risk of adenoma recurrence and optimal surveillance is not well defined. The objective of this study was to characterize the timing and frequency of rectal adenoma recurrence after removal by transanal endoscopic surgery and identify recurrence risk factors. This was a retrospective cohort study of a large, single-center academic institution in Vancouver, BC, Canada. Consecutive patients between May 1, 2007 and September 30, 2016 with pathology-confirmed rectal adenoma treated by primary excision with transanal endoscopic surgery and at least 1 year of confirmed endoscopic follow-up were included. Main outcome measures were recurrence rates following TEM as well as risk factors for recurrence. 297 patients met inclusion criteria. The mean age of patients was 66.5 ± 11.5 years and 57.9% were male. Median follow-up was 623 (range 56–3841) days. A total of 62 recurrences occurred in 41 patients (13.8% of study population). Recurrences were managed with repeat transanal endoscopic surgery or endoscopic resection 67.7% and 25.8% of the time, respectively. Radical resection was required for adenocarcinoma in 4 patients. Recurrence-free survival rates were 93.4% at 1 year, 86.2% at 2 years, and 73.1% at 5 years. After adjusting for individual surgeons, adenoma height, size > 3 cm, high-grade dysplasia, positive margins, and management of the rectal defect, patients who underwent surgery in the latter 5 years of the study had lower odds of recurrence (OR 0.42, 95% CI 0.19, 0.93, p = 0.03). Rectal adenomas managed by transanal endoscopic surgery are lesions at high risk for recurrence; surveillance should be performed within the first 2 years and continued for a total of at least 5 years. Most recurrences can be successfully treated with repeat TEM or endoscopic resection.

Multiple challenges exist when performing high-quality TME surgery for malignancy via the traditional “top-down” abdominal approach. Patients who are male, are obese, have a narrow pelvis, or have low, bulky tumors may present a particular challenge. The “bottom-up” approach of taTME overcomes many of these technical challenges and facilitates minimally invasive surgery. This may lead to improvements in TME quality, but long-term outcomes are not yet known. Appropriate patient selection and surgeon training are critical to ensure good outcomes with the use of taTME for patients with rectal malignancy.

3508 Background: CO.28 (NCT03259035) is a phase II study designed to determine if patients with cT1-T3a/bN0 rectal cancer can be treated with induction chemotherapy (FOLFOX/CAPOX) and organ-preserving surgery. Methods: Patients with MRI staged cT1-3a/bN0 tumors and no pathologic (p) high risk features received 6/4 cycles of FOLFOX/CAPOX, repeat sigmoidoscopy/pelvic MRI and subsequent Transanal Endoscopic Surgery (TES) in the absence of tumor progression. ypT0/T1N0 tumors were treated with observation while ypT2+ or ypN+ stage were recommended Total Mesorectal Excision (TME). The primary endpoint was protocol specified Organ Preservation Rate (psOPR = ypT0/T1N0, no p high risk features) and actual Organ Preservation Rate (aOPR = ypT0/T1N0 stage plus higher yp stage patients who declined TME surgery). The study would be considered negative with an psOPR of 50% or lower (H0) and as promising if it is 65% or higher (H1). Results: Between 08/2017 to 05/2020, 58 eligible patients were accrued in Canada and the United States, median age was 67 years, 71% male. All had well-moderately differentiated, non-mucinous rectal adenocarcinoma and median tumor height was 6 cm (range 0-18). Median follow-up was 15.4 months. Chemotherapy with FOLFOX (32) or CAPOX (26) was administered, 90% completed all planned cycles. A total of 56/58 (97%) proceeded to TES, while one patient was ineligible due to tumor progression (1.7%) and one declined. In the intention to treat analysis, the psOPR was 57% (95% CI 43-70%) while the aOPR was 79% (95% CI 67% to 89%) due to 13/23 declining recommended TME surgery. Of 10 patients who proceeded to recommended TME, a complete R0 TME was performed in 9/10, and no p residual carcinoma was found in 7/10. Crude loco-regional (LR) and distant recurrence rates were 3.5% (95% CI 0.4 to 12%) and 0%, respectively. A recurrence occurred in 1/13 patients who initially declined TME surgery. Conclusions: In select patients with early stage rectal cancer, three months of induction CAPOX/FOLFOX followed by TES resulted in a high OPR without the use of pelvic irradiation. The observed high rate of pathologic downstaging may point to high chemo-responsiveness in early rectal adenocarcinoma with no p high risk features. Further trials to evaluate this approach are justified and updated results will be presented. Clinical trial information: NCT03259035. [Table: see text]

Importance Proponents of novel transanal total mesorectal excision (TME) suggest the procedure overcomes the technical and oncologic challenges of conventional approaches for treating rectal cancer. Recently, however, there has been controversy regarding the oncologic safety of the procedure. Objective To assess the association of transanal TME with the incidence of local recurrence (LR) of cancer and the probability of remaining free of LR during follow-up. Design, Setting, and Participants This multicenter cohort study used data from 8 high-volume rectal cancer academic institutions from across Canada on all consecutive patients with primary rectal cancer treated by transanal TME at the participating centers. The study was conducted between January 2014 and December 2018, and data were analyzed from April 1, 2020, to September 15, 2020. Exposure Transanal TME. Main Outcomes and Measures The incidence of LR was reported as a direct measure of quality of resection. The cumulative probability of LR- and systemic recurrence (SR)–free survival at 36 months was estimated. Local recurrence and SR were defined as radiologic or endoscopic evidence of 1 or more new lesions in or outside the pelvis, respectively, documented during surveillance after the removal of the primary tumor. Results Of 608 total patients included in the analysis, 423 (69.6%) were male; the median age was 63 years (interquartile range [IQR], 54-70 years). Local recurrence was identified in 22 patients (3.6%) after a median follow-up of 27 months (IQR, 18-38 months). The median time to LR was 13 months (IQR, 9-19 months). Sixteen of the 22 patients with LR (72.7%) were male, 14 (63.6%) received neoadjuvant chemoradiation, and 12 (54.5%) had American Joint Committee on Cancer stage III disease. Of those with LR, 16 (72.7%) had a negative circumferential radial margin and 20 (90.9%) had a negative distal resection margin, 2 (9.1%) experienced conversion to open surgery, and 15 (68.2%) also developed SR. The probability of LR-free survival at 36 months was 96% (95% CI, 94%-98%). According to the Cox proportional hazards regression model, the hazard ratio of LR was estimated to be 4.2 (95% CI, 2.9-6.2) times higher among patients with a positive circumferential radial margin than among those with a negative circumferential radial margin. Conclusions and Relevance In this cohort study, transanal TME performed by experienced surgeons was associated with an incidence of LR and SR that is in line with the published literature on open and laparoscopic TME, suggesting that transanal TME may be an acceptable approach for management of rectal cancer.

Objectives Optimal treatment of rectal cancer (RC) requires multidisciplinary care. We examined whether distance to treatment center or community size impacts access to multimodality care and population-based outcomes in RC. Methods Patients diagnosed with stage II/III RC from 1999 to 2009 and treated at 1 of 6 regional cancer centers in British Columbia were reviewed. Distance to treatment center was determined for each patient. Communities were classified as rural, small, medium, and large population centers. Logistic and Cox regression models assessed associations of distance and community size with treatment received as well as cancer-specific (CSS) and overall survival (OS). Results Of 3,158 patients, 93.6% underwent surgery, 86.3% received radiotherapy, and 51.3% were treated with adjuvant chemotherapy (AC). Median time from diagnosis to oncologic consultation was longer for those >100 km from a treatment center or residing in medium/rural communities. Logistic regression demonstrated no correlation between distance or community size and receipt of treatment modality. Univariate analysis showed similar CSS (P = .18, .88) and OS (P = .36, .47) based on community size and distance, respectively. In multivariate analysis, distance >100 km had inferior CSS (Hazard Ratio [HR] 1.39, 95% CI: 1.03-1.88; P = .031). There was no consistent trend between decreasing community size and outcomes; however, living in a small center was associated with improved OS (HR 0.58, 95% CI: 0.38-0.88; P = .011) and CSS (HR 0.42, 95% CI: 0.25-0.70; P = .001). Conclusions In this population-based study, there were no urban-rural differences in access to multidisciplinary care, but increased distance may be associated with worse cancer-specific outcomes.

Sexual health is an integral component of quality of life for cancer survivors, and is often negatively impacted by treatment. Geographic limitations often prohibit survivors from accessing sexual health programs designed to address their needs. This study examined the efficacy of an online, 12-week psychoeducational program, which included elements of mindfulness meditation, for sexual difficulties in survivors of colorectal or gynecologic cancer. Complete pre- and postintervention data were available for 46 women (mean age 55.0, SD 9.6) and 15 men (mean age 59.7, SD 6.8). Women experienced significant improvements in sex-related distress (p < .001), sexual function (p < .001 and p < .01), and mood (p < .001); these results were maintained at six months follow-up. Men's improvement in desire was not significant (p = .06), whereas intercourse satisfaction was (p < .05) immediately after the program, but not at follow-up. In order to more fully explore women's experiences, interviews were carried out with six participants and analyzed using narrative inquiry. Women shared a feeling of renewed hope for regaining their sex lives, and expressed that they would have valued an interactive component to the program. These findings suggest that an online, unidirectional psychoeducational program is feasible, and may be effective for women survivors of gynecologic and colorectal cancer, but further work is needed to ensure that online interventions address the sexual health needs of male survivors.

To determine whether closure of the defect created during full thickness excision of a rectal lesion with transanal endoscopic microsurgery (TEM) leads to fewer complications when compared to leaving the defect unsutured. This is a single-center cohort study using a prospectively maintained database. All patients ≥18 years old treated with full thickness TEM with no compromise of the peritoneal cavity were included. Two cohorts were established: patients with the defect sutured and patients with the defect left open. Demographic, operative, and pathologic data were compared. The main outcome analyzed was early (

Total mesorectal excision has long been the standard of care for patients with rectal cancer. However, in select patients, local excision is an appropriate alternative option. The role of adjuvant radiation therapy in patients treated with local excision is controversial and evidence is lacking.The purpose of this study was to report oncological outcomes of patients with rectal cancer treated with local excision and adjuvant radiation.This study was a retrospective chart review.The study was conducted at the BC Cancer Agency, a tertiary referral hospital.A total of 93 patients with node-negative rectal cancer treated with local excision and adjuvant radiotherapy between 2001 and 2010 were included in the study.Patient and tumor characteristics are reported. Five-year local control, progression-free survival, and overall survival were analyzed using Kaplan-Meier methods.Five-year overall survival, local control, and progression-free survival for patients treated with local excision and adjuvant radiotherapy were 78.5%, 86.1%, and 83.8%. In T1 disease, local control was 92.5%.Referral bias, selection bias, lack of uniform surveillance, and retrospective analysis are the study limitations.Local excision with adjuvant radiotherapy provides a good level of local control in T1 disease and remains a good treatment option for patients who are either medically not suitable for a more radical surgical approach or who refuse this procedure. Local excision and radiotherapy should not be advocated in T2/T3 disease; however, it can provide a good alternative in those patients who are not fit enough for a more radical operation.

Formalin fixation is the standard method for the preservation of tissue for diagnostic purposes, including pathologic review and molecular assays. However, this method is known to cause artifacts that can affect the accuracy of molecular genetic test results. We assessed the applicability of alternative fixatives to determine whether these perform significantly better on next-generation sequencing assays, and whether adequate morphology is retained for primary diagnosis, in a prospective study using a clinical-grade, laboratory-developed targeted resequencing assay. Several parameters relating to sequencing quality and variant calling were examined and quantified in tumor and normal colon epithelial tissues. We identified an alternative fixative that suppresses many formalin-related artifacts while retaining adequate morphology for pathologic review.

Transanal endoscopic microsurgery (TEM) is the treatment of choice for benign rectal tumors and select early rectal cancers. This surgical approach has become ubiquitous and surgeons are seeing recurrent lesions after TEM resection. This study aims to outline the safety and outcomes of repeat TEM when compared to primary TEM procedures.At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for patients treated by TEM are maintained in a prospectively populated database. Two groups were established for comparison: patients undergoing first TEM procedure (TEM-P) and patients undergoing repeat TEM procedure (TEM-R).Between 2007 and 2017, 669 patients had their first TEM procedure. Over this time frame, 57 of these patients required repeat TEM procedures, including 15 of these patients treated by 3 or more TEMs. Indications for repeat TEM included recurrence (78%), positive margins (15%), and metachronous lesions (7%). There were no differences between the groups in patient age, gender, or tumor histology. Compared to TEM-P, TEM-R had shorter operative times (38 vs. 52 min, p 0.001), more distal lesions (5 vs. 7 cm, p 0.004), and smaller lesions (3 vs. 4 cm, p 0.0003). The TEM-R group had similar length of hospital stay (0.45 vs. 0.56 days, p = 0.65), rates of clear margins on pathology (81% vs. 88%, p = 0.09), and 30-day readmission rates (7% vs. 4%, p = 0.27) when compared to TEM-P group. TEM-R was more likely to be managed without suturing the surgical defect (72% vs. 32%, p 0.0001). Repeat TEM was associated with similar post-operative complications as primary TEM graded on the Clavien-Dindo classification scale (Grade 1: 5% vs. 5%, Grade 2: 5% vs. 4%, Grade 3: 5% vs. 1%, p = 0.53). No 30-day mortality occurred in either group.The St. Paul's Hospital TEM experience suggests repeat TEM is a safe and feasible procedure with similar outcomes as patients undergoing first TEM.

BACKGROUND: Following colonoscopy or esophagogastroduodenoscopy (EGD), the physician reports their findings, which are typically transcribed and kept in patient’s medical records. The completeness of endoscopic dictation reports are quality indicators for endoscopic practice. Several guidelines outlining the key elements of endoscopic reports were used to develop a dictation template at St. Paul’s Hospital in 2013. AIMS: The purpose of this study is to assess and compare the quality and completeness of endoscopic procedure reports from 2008 and 2014 for physicians currently working at St. Paul’s Hospital to determine if key quality elements of documentation were more consistently included following institution of a dictation template. METHODS: A retrospective chart review of endoscopic reports of 9 physicians were reviewed at two time points, before (2008) and after (2014) the introduction of the dictation template. 150 charts were reviewed for each doctor in each year. Data was collected from a comprehensive EMR review that included demographics, patient history, procedure report details (appropriate quality indicators as outlined by ASGE Guidelines), and length of procedure. Cecal visualization rate and polyp detection rate were also calculated for colonoscopy reports. This study was approved by the IRB at St Paul’s Hospital. RESULTS: The overall completeness for colonoscopy reporting for all quality data points improved from 70.5% in 2008 to 90.6% in 2014 (p

ObjectivesCovert stroke after non-cardiac surgery may have substantial impact on duration and quality of life. In non-surgical patients, covert stroke is more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac surgery.NeuroVISION is a multicentre, international, prospective cohort study that will characterise the association between perioperative acute covert stroke and postoperative cognitive function.Setting and participantsWe are recruiting study participants from 12 tertiary care hospitals in 10 countries on 5 continents.ParticipantsWe are enrolling patients ≥65 years of age, requiring hospital admission after non-cardiac surgery, who have an anticipated length of hospital stay of at least 2 days after elective non-cardiac surgery that occurs under general or neuraxial anaesthesia.Primary and secondary outcome measuresPatients are recruited before elective non-cardiac surgery, and their cognitive function is measured using the Montreal Cognitive Assessment (MoCA) instrument. After surgery, a brain MRI study is performed between postoperative days 2 and 9 to determine the presence of acute brain infarction. One year after surgery, the MoCA is used to assess postoperative cognitive function. Physicians and patients are blinded to the MRI study results until after the last patient follow-up visit to reduce outcome ascertainment bias.We will undertake a multivariable logistic regression analysis in which the dependent variable is the change in cognitive function 1 year after surgery, and the independent variables are acute perioperative covert stroke as well as other clinical variables that are associated with cognitive dysfunction.ConclusionsThe NeuroVISION study will characterise the epidemiology of covert stroke and its clinical consequences. This will be the largest and the most comprehensive study of perioperative stroke after non-cardiac surgery.Trial registration numberNCT01980511

Very few patients admitted for diverticulitis will require emergent surgery, with failure of medical management and free perforation being the most common indications. The surgical management of perforated diverticulitis is still evolving from a three-stage procedure in the mid-twentieth century to either Hartmann’s procedure or primary anastomosis nowadays. The morbidity associated with Hartmann’s reversal has led to increased interest toward primary anastomosis. Although several studies have attempted to determine which approach is most beneficial to the patients, it remains a controversial topic due to the lack of strong evidence. In this chapter, we aim to review the different options for resection in the case of perforated diverticulitis and present the available literature that supports each of them.

Surgical site infections of up to 27% are reported for colorectal surgery. Care bundles have been introduced to decrease surgical site infection rates, but are variable in composition.This study aimed to determine whether the addition of a "Colorectal Closure Bundle" in our Enhanced Recovery After Surgery pathway decreased surgical site infection rates.This is a retrospective study of elective colon resections before and after the addition of a closure bundle.This study was conducted at a single academic institution.Patients undergoing consecutive elective colon resections with primary anastomosis, December 2012 to July 31, 2014, enrolled in our Enhanced Recovery After Surgery pathway. Exclusion criteria were stoma creation and closure and preoperative chemoradiation.The "Colorectal Closure Bundle," which includes a change in gown and gloves, redraping, wound lavage, and a new set of instruments for closure, was added to the Enhanced Recovery After Surgery pathway.The primary outcome measured was surgical site infections as defined by CDC criteria.Two hundred five patients were reviewed, 111 preintervention and 94 postintervention. Overall surgical site infection rates were 25.2% preintervention vs 26.6% postintervention (p = 0.82). Surgical site infections were subdivided into "superficial" and "deep and organ space" and were 14.4% and 10.8% preintervention vs 14.9% and 11.7% postintervention (p = not significant). Smoking and diabetes mellitus were found to be independently associated with surgical site infections on multivariate analysis, with adjusted odds ratios of 4.32 (95% CI, 1.70-10.94), p = 0.002, and 2.87 (95% CI 1.30-6.34), p = 0.009.Limitations include the retrospective nature of the study and the small sample size.There was no change in surgical site infection rates after implementation of the "Colorectal Closure Bundle." Smoking and diabetes mellitus were the only significant risk factors associated with increased surgical site infections. Our infection rates remain high and further change in our perioperative protocol is needed.

Background Controversy exists about whether cutting diathermy for skin incisions leads to a cosmetically inferior scar. Cosmetic outcomes were compared between skin incisions created with cutting diathermy versus scalpel. Wound infection rates and postoperative incisional pain were also compared. Methods This was a randomized double-blind trial comparing cutting diathermy and scalpel in patients undergoing bowel resection. Scar cosmesis was assessed at 6 months after surgery by a plastic surgeon and a research associate using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). Patients also used POSAS to self-evaluate their scars. Wound infections within 30 days were recorded, and incision pain scores were measured on the first 5 days after operation. Results A total of 66 patients were randomized to cutting diathermy (31) or scalpel (35). At 6 months, there was no significant difference between the diathermy and scalpel groups in mean(s.d.) VSS scores (4·9(2·6) versus 5·0(1·9); P = 0·837), mean POSAS total scores (19·2(8·0) versus 20·0(7·4); P = 0·684) or subjective POSAS total scores (20·2(12·1) versus 21·3(10·4); P = 0·725). Neither were there significant differences in wound infection rates between the groups (5 of 30 versus 5 of 32; P = 1·000). Pain scores on day 1 after operation were significantly lower in the diathermy group (mean 1·68 versus 3·13; P = 0·018), but were not significantly different on days 2–5. Conclusion Cutting diathermy is a cosmetically acceptable technique for abdominal skin incisions. There is no increased risk of wound infection, and diathermy may convey benefit in terms of early postoperative wound pain. Registration number: NCT01496404 (http://www.clinicaltrials.gov).

Background High urinary infection (UTI) rate (12%) for our rectal surgery prompted practice change to early catheter removal (postoperative day 2) and prophylactic tamsulosin. Here we report urinary retention (UR) and UTI after this change. Methods Retrospective cohort study in male patients 50+ years undergoing elective colorectal surgery from July 2015 to July 2017. Multivariate regression was used to determine risk factors for urinary retention. Results 157 patients, 57 without and 100 with tamsulosin had UR 11.46% and UTI 5.13%. Of all potential risk factors, ileus (OR 5.50, 95% CI: 1.86–16.24) was an independent risk factor for urinary retention. Conclusions Urinary retention of 11% after colorectal resection is within literature range and associated with post-operative ileus. Tamsulosin did not affect UR in our small study sample. Early catheter removal was associated with decreased UTI rate.

Summary Background Climate change is a major global public health priority. The delivery of health-care services generates considerable greenhouse gas emissions. Operating theatres are a resource-intensive subsector of health care, with high energy demands, consumable throughput, and waste volumes. The environmental impacts of these activities are generally accepted as necessary for the provision of quality care, but have not been examined in detail. In this study, we estimate the carbon footprint of operating theatres in hospitals in three health systems. Methods Surgical suites at three academic quaternary-care hospitals were studied over a 1-year period in Canada (Vancouver General Hospital, VGH), the USA (University of Minnesota Medical Center, UMMC), and the UK (John Radcliffe Hospital, JRH). Greenhouse gas emissions were estimated using primary activity data and applicable emissions factors, and reported according to the Greenhouse Gas Protocol. Findings Site greenhouse gas evaluations were done between Jan 1 and Dec 31, 2011. The surgical suites studied were found to have annual carbon footprints of 5 187 936 kg of CO 2 equivalents (CO 2 e) at JRH, 4 181 864 kg of CO 2 e at UMMC, and 3 218 907 kg of CO 2 e at VGH. On a per unit area basis, JRH had the lowest carbon intensity at 1702 kg CO 2 e/m 2 , compared with 1951 kg CO 2 e/m 2 at VGH and 2284 kg CO 2 e/m 2 at UMMC. Based on case volumes at all three sites, VGH had the lowest carbon intensity per operation at 146 kg CO 2 e per case compared with 173 kg CO 2 e per case at JRH and 232 kg CO 2 e per case at UMMC. Anaesthetic gases and energy consumption were the largest sources of greenhouse gas emissions. Preferential use of desflurane resulted in a ten-fold difference in anaesthetic gas emissions between hospitals. Theatres were found to be three to six times more energy-intense than the hospital as a whole, primarily due to heating, ventilation, and air conditioning requirements. Overall, the carbon footprint of surgery in the three countries studied is estimated to be 9·7 million tonnes of CO 2 e per year. Interpretation Operating theatres are an appreciable source of greenhouse gas emissions. Emissions reduction strategies including avoidance of desflurane and occupancy-based ventilation have the potential to lessen the climate impact of surgical services without compromising patient safety. Funding None.

Background A diverting stoma is an accepted adjunct to low anterior resection (LAR) for rectal cancer. However, some patients do not undergo a subsequent procedure to have the stoma reversed. We aim to determine incidence and risk factors for nonclosure of the diverting stoma. Methods This is a retrospective study of stage I to III rectal cancer patients at a single institution having LAR with curative intent and a diverting stoma. Results We studied 162 patients. Prevalence of nonclosure of the temporary stoma was 14.5% within 13 months of the index surgery. On a multivariate linear regression model, nonclosure was associated with anastomotic leak (odds ratio 9.89, 2.31 to 43.93, P P Conclusions Prevalence of nonclosure of a diverting stoma after LAR for rectal cancer is substantial (14.5%). Patients should be counselled regarding this risk with particular attention to potential risk factors.

Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.Les adénomes et les cancers du rectum sont fréquents. Il est possible de procéder à l’exérèse des petits adénomes par voie coloscopique, tandis que la résection des polypes plus volumineux se fera par exérèse trans-anale classique. En raison de difficultés d’ordre technique, les adénomes des portions moyenne et supérieure du rectum nécessitent une résection radicale. La microchirurgie endoscopique trans-anale (MCET) a d’abord été conçue comme une solution de rechange pour le traitement de ces lésions. Toutefois, depuis son avènement, la MCET a également été utilisée pour diverses lésions rectales, dont les carcinoïdes, les prolapsus et diverticules rectaux, les carcinomes au stade précoce et la résection palliative des cancers rectaux. L’objectif de la présente revue est de décrire la situation actuelle de la MCET pour ce qui est du traitement des lésions rectales. Depuis les années 1980, la MCET a connu des progrès substantiels. Compte tenu du faible taux de récurrences qui l’accompagne, il s’agit de la méthode de choix pour la résection des adénomes dont l’exérèse endoscopique est impossible. Certaines études ont montré les avantages de son utilisation pour le traitement des cancers rectaux précoces de stade T1, comparativement à la chirurgie radicale chez certains patients. Toutefois, pour les cancers rectaux plus avancés, la MCET doit être considé rée comme une mesure palliative ou expérimentale. Cette technique s’est aussi révélée sécuritaire pour le traitement d’autres tumeurs rectales rares, comme les carcinoïdes. La MCET pourrait ouvrir la voie à de nouvelles stratégies pour le traitement des pathologies du rectum, là où les limites des techniques trans-anales offrent peu d’innovations en termes de chirurgie endoluminale.

Canadian Association of General Surgeons, the American College of Surgeons, the Canadian Society of Colorectal Surgeons, and the American Society of Colorectal Surgeons Evidence Based Reviews in Surgery : Colorectal Surgery

Importance Chemoradiotherapy (CRT), followed by surgery, is the recommended approach for stage II and III rectal cancer. While CRT decreases the risk of local recurrence, it does not improve survival and leads to poorer functional outcomes than surgery alone. Therefore, new approaches to better select patients for CRT are important. Objective To conduct a phase 2 study to evaluate the safety and feasibility of using magnetic resonance imaging (MRI) criteria to select patients with “good prognosis” rectal tumors for primary surgery. Design, Setting, and Participants Prospective nonrandomized phase 2 study at 12 high-volume colorectal surgery centers across Canada. From September 30, 2014, to October 21, 2016, a total of 82 patients were recruited for the study. Participants were patients newly diagnosed as having rectal cancer with MRI-predicted good prognosis rectal cancer. The MRI criteria for good prognosis tumors included distance to the mesorectal fascia greater than 1 mm; definite T2, T2/early T3, or definite T3 with less than 5 mm of extramural depth of invasion; and absent or equivocal extramural venous invasion. Interventions Patients with rectal cancer with MRI-predicted good prognosis tumors underwent primary surgery. Main Outcomes and Measures The primary outcome was the proportion of patients with a positive circumferential resection margin (CRM) rate. Assuming a 10% baseline probability of a positive CRM, a sample size of 75 was estimated to yield a 95% CI of ±6.7%. Results Eighty-two patients (74% male) participated in the study. The median age at the time of surgery was 66 years (range, 37-89 years). Based on MRI, most tumors were midrectal (65% [n = 53]), T2/early T3 (60% [n = 49]), with no suspicious lymph nodes (63% [n = 52]). On final pathology, 91% (n = 75) of tumors were T2 or greater, 29% (n = 24) were node positive, and 59% (n = 48) were stage II or III. The positive CRM rate was 4 of 82 (4.9%; 95% CI, 0.2%-9.6%). Conclusions and Relevance The use of MRI criteria to select patients with good prognosis rectal cancer for primary surgery results in a low rate of positive CRM and suggests that CRT may not be necessary for all patients with stage II and III rectal cancer. Trial Registration ISRCTN.com identifier:ISRCTN05107772

TPS724 Background: CO.28 is a phase II study which aims to determine if patients with stage I/II rectal cancer can be treated with induction chemotherapy (FOLFOX/CAPOX) and organ-preserving transanal microsurgery. Prior studies have explored the use of pelvic chemoradiation followed by transanal microsurgery as a means to increase organ preservation. However, pre-operative radiation may have acute and prolonged impacts such as wound complications and adverse on sphincter, sexual and urinary function. Moreover, patients who develop recurrence following this strategy are difficult to salvage as re-irradiation is not usually an option. There is virtually no prospective experience of neoadjuvant FOLFOX/CAPOX chemotherapy and excision for early rectal tumors. Methods: The primary objective is to determine the rate of organ preservation and the trial will be successful if more than 65% of patients avoid a formal rectal resection. In this two-staged phase II trial, patients are eligible if they have clinical N0 and T1-T3a/bN0M0 rectal tumors and no pathologic high risk features. After 6 cycles of q2weekly FOLFOX or 4 cycles of CAPOX, rectal endoscopy and pelvic MRI are repeated and if there is evidence of tumor response, patients proceed to tumor excision by Transanal Endoscopic Microsurgery (TEMS) or Transanal Minimally Invasive Surgery (TAMIS). It is required that participating surgeons have a minimum experience of 20 TEMS/TAMIS procedures and they are asked to submit an unedited video for central review. Pathologic ypT0 or ypT1N0 tumors are assigned to observation while ypT2+ or any ypN+ tumors are treated with radical surgery and total mesorectal excision (TME). Pre-operative pelvic radiation is suggested only for ypT3+ or node positive tumors. Endoscopic and cross-sectional imaging is repeated every 4-6 months for 36 months. Circulating tumor DNA (ctDNA) will be correlated with tumor response and relapse. A total of 58 patients will be accrued. Study Progress: The study was activated in Canada in late 2017 and at select US Cancer Centers in 2018, with total accrual to date of 4 patients. (NCT03259035) Clinical trial information: NCT03259035.

In Canada, provincial cancer registries have been established to provide rigorous population-based data for patients with colorectal cancer. Databases maintained by regional cancer agencies contain a broader scope of information and have been used as a surrogate source of information for colorectal cancer research. It is unclear whether these data can be reliably extrapolated to all patients affected by colorectal cancer. We sought to determine whether patients included in a referral-based database are systematically different from patients who are not included.We conducted a retrospective cohort study to compare patients referred to the British Columbia Cancer Agency with those who were not referred. Comparison was based on age, sex and geographic location. We used univariate and logistic regression analysis to identify significant differences between the cohorts.Univariate analysis demonstrated that the referral and nonreferral cohorts differed in sex, age and geographic location. For patients with rectal cancer, the referral and nonreferral cohorts varied in age and geographic location. Multivariate analysis demonstrated significant differences in age and geographic location but not sex for patients with colon and rectal cancer.Patients included in the referral database differed in age and geographic location from those included only in the provincial database. Studies using large data sets from referral centres must be interpreted with caution and may not be representative of the entire patient population.Au Canada, on a établi des registres provinciaux en oncologie pour générer des données représentatives rigoureuses au sujet des patients atteints de cancer colorectal. Les bases de données maintenues par les agences régionales du cancer contiennent un éventail plus large de renseignements et ont servi de source de données de substitution pour la recherche sur le cancer colorectal. Or, on ignore s’il est possible d’extrapoler ces données de manière fiable à tous les patients atteints de cancer colorectal. Nous avons voulu déterminer si les patients inclus dans une base de données de référence sont systématiquement différents des patients qui n’y figurent pas.Nous avons procédé à une étude de cohorte rétrospective pour comparer les patients référés à l’agence de lutte contre le cancer de la Colombie-Britanniqueà ceux qui n’y avaient pas été référés. La comparaison reposait sur l’âge, le sexe et l’emplacement géographique. Nous avons utilisé une analyse de régression univariée et logistique pour dégager les différences significatives entre les cohortes.L’analyse univariée a démontré que les cohortes référée et non référée différaient aux plans du sexe, de l’âge et de l’emplacement géographique. Pour les patients atteints d’un cancer rectal, les cohortes référée et non référée variaient selon l’âge et l’emplacement géographique. L’analyse multivariée a révélé des différences significatives aux plans de l’âge et de l’emplacement géographique, mais non au plan du sexe en ce qui concerne les patients atteints de cancer du côlon et du rectum.Les patients inclus dans la base de données de référence étaient différents de ceux qui ne figuraient que dans la base de données provinciale, pour ce qui est de l’âge et de l’emplacement géographique. Il faut interpréter avec prudence lesétudes reposant sur d’importantes séries de données provenant de centres de référence, car elles pourraient ne pas être représentatives de toute la population de patients.

Evidence-Based Reviews in Surgery (EBRS) is a program developed to teach critical appraisal skills to general surgeons and residents. The purpose of this study was to assess the use of EBRS by general surgery residents across Canada and to assess residents' opinions regarding EBRS and journal clubs.We surveyed postgraduate year 2-5 residents from 15 general surgery programs. Data are presented as percentages and means.A total of 231 residents (58%, mean 56% per program, range 0%-100%) responded: 172 (75%) residents indicated that they know about EBRS and that it is used in their programs. More than 75% of residents who use EBRS agreed or strongly agreed that the EBRS clinical and methodological articles and reviews are relevant. Only 55 residents (24%) indicated that they used EBRS online. Most residents (198 [86%]) attend journal clubs. The most common format is a mandatory meeting held at a special time every month with faculty members with epidemiological and clinical expertise. Residents stated that EBRS articles were used exclusively (13%) or in conjunction with other articles (57%) in their journal clubs. Most respondents (176 of 193 [91%]) stated that journal clubs are very or somewhat valuable to their education.The EBRS program is widely used among general surgery residents across Canada. Although most residents who use EBRS rate it highly, a large proportion are unaware of EBRS online features. Thus, future efforts to increase awareness of EBRS online features and increase its accessibility are required.Le programme de revues factuelles en chirurgie EBRS (Evidence-Based Reviews in Surgery) a été mis au point pour enseigner aux chirurgiens et aux résidents en chirurgie générale les compétences nécessaires pour faire des évaluations critiques. Le but de cette étude était d'analyser l'utilisation des EBRS par les résidents en chirurgie générale au Canada et de leur demander leur opinion au sujet des EBRS et des clubs de lecture.Nous avons interrogé des résidents des années 2 à 5 rattachés à 15 programmes de chirurgie générale. Les données sont présentées sous forme de pourcentages et de moyennes.En tout, 231 résidents (58 %, moyenne de 56 % par programme, intervalle 0 %–100 %) ont répondu : 172 résidents (75 %) ont indiqué qu'ils connaissent les EBRS et que leur programme les utilise. Plus de 75 % des résidents qui utilisent les EBRS se sont dit d'accord ou tout à fait d'accord avec l'énoncé sur la pertinence des articles et revues cliniques et méthodologiques des EBRS. Seulement 55 résidents (24 %) ont dit utiliser les EBRS en ligne. La plupart des résidents (198 [86 %]) participaient à des clubs de lecture. Leur utilisation la plus courante prend la forme d'une réunion obligatoire tenue à un moment particulier tous les mois avec les enseignants de la faculté ayant une expertise épidémiologique et clinique. Les résidents ont indiqué que les EBRS étaient utilisés seuls (13 %) ou avec d'autres articles (57 %) dans leurs clubs de lecture. La plupart des répondants (176 sur 193 [91 %]) ont affirmé que leurs clubs de lecture sont très ou assez utiles pour leur formation.Le programme EBRS est largement utilisé par les résidents en chirurgie générale au Canada. Même si la plupart des résidents qui utilisent les EBRS leur accordent une cote élevée, une forte proportion ignore l'existence des possibilités web des EBRS. Il faudra donc travailler à mieux faire connaître les possibilités offertes par le programme EBRS sur le web et en faciliter l'accès.

Anal dilation during tumour excision with transanal endoscopic microsurgery (TEM) has caused concerns regarding postoperative anal function. We sought to determine whether TEM affects anorectal function and quality of life.All patients undergoing TEM between March 2007 and December 2008 were considered for inclusion. We excluded patients who were treated with subsequent radical resection, unavailable for interview or deceased. Patients were interviewed by phone to measure the preoperative and postoperative function using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire- Core 30 (EORTC QLQ-C30) and Core 38 (CR38) instruments, the Fecal Incontinence Severity Index (FISI) and the Fecal Incontinence Quality of Life (FIQL) questionnaires. Statistical analysis involved the Wilcoxon signed rank test and Spearman rank correlation coefficient.Forty patients received TEM; 30 of them met all inclusion criteria and agreed to participate. The median age was 70 (42-93) years, and median follow-up time between the interview and the operation was 365 (55-712) days. Tumours excised included 19 adenomas, 8 carcinomas and 3 carcinoid tumours. The median distance from the tumour to the anal verge was 6.5 (2-13) cm. Median length of stay was 1 (0-12) day. For most aspects of quality of life, there were no detectable differences after surgery. The EORTC QLQ-C30 showed a significant improvement in diarrhea (27.8 v. 10, p = 0.002). The FIQL scores improved with surgery (3.59 v. 3.85, p = 0.020). There was no difference in pre- versus postoperative FISI scores (6.7 v. 6.3, p = 0.93).Despite a large operating rectoscope, TEM improves quality of life related to fecal incontinence and does not have a negative impact on fecal continence.La dilatation de l'anus au cours de l'excision d'une tumeur par microchirurgie endoscopique transanale (MET) soulève des préoccupations quant à la fonction anale postopératoire. Nous avons cherché à déterminer si la MET a un effet sur la fonction anorectale et la qualité de vie.Nous avons envisagé d'inclure tous les patients ayant subi une MET entre mars 2007 et décembre 2008. Nous avons exclu les patients qui ont été traités par résection radicale subséquente, qui n'étaient pas disponibles pour une entrevue ou qui étaient décédés. Nous avons interviewé les patients par téléphone pour mesurer la fonction préopératoire et postopératoire au moyen du Questionnaire sur la qualité de vie — Base 30 de l'Organisation européenne de recherche sur le traitement du cancer (EORTC QLQC30) et Base 38 (CR38), l'Indice de sévérité de l'incontinence fécale (ISIF) et la qualité de vie liée à l'incontinence fécale (QVIF). L'analyse statistique a comporté le test de Wilcoxon pour observations appariées et le coefficient de corrélation de rang de Spearman.Sur les 40 patients qui ont subi une MET, 30 répondaient à tous les critères d'inclusion et ont consenti à participer. L'âge médian était de 70 (42–93) ans et le temps médian du suivi qui s'est écoulé entre l'entrevue et l'opération s'est établi à 365 (55–712) jours. Les tumeurs excisées comportaient 19 adénomes, 8 carcinomes et 3 tu meurs carcinoïdes. La distance moyenne entre la tumeur et la marge de l'anus était de 6,5 (2–13) cm. La durée médiane du séjour était de 1 (0–12) jour. Pour la plupart des aspects de la qualité de vie, il n'y avait pas de différence détectable après l'intervention chirurgicale. Le questionnaire EORTC QLQ-C30 a révélé une amélioration importante au niveau de la diarrhée (27,8 c. 10,En dépit de la grosseur du rectoscope utilisé pendant l'intervention, la MET améliore la qualité de vie liée à l'incontinence fécale et n'a pas d'effet négatif sur la continence fécale.

Our study aims were to measure the associations between body mass index (BMI) and body surface area (BSA) with outcomes for stage II and III colon cancer and to evaluate if the effect of obesity is modified by disease stage and receipt of adjuvant therapy.Using a prospective cohort of stage II and III colon cancer patients who were referred between 2001 and 2005, we compared 3-year relapse-free survival (3-year RFS), 5-year cancer-specific survival (5-year CSS), and 5-year overall survival (5-year OS) rates among different BMI and BSA categories. Cox proportional-hazards models were constructed to explore the relationships between different body compositions and outcomes while adjusting for confounders.Postoperative height and weight were used to classify 913 patients as normal weight (n = 424, BMI25 kg/m(2)), overweight (n = 319, BMI 25-30 kg/m(2)), and obese (n = 170, BMI30 kg/m(2)). Using Mosteller formula, 684 subjects had normal BSA (≤ 2.0 m(2)) and 229 had high BSA (2.0 m(2)). Obese subjects experienced similar 3-year RFS (61.9 vs. 66.5 vs. 63.6 %, p = 0.51), 5-year CSS (65.6 vs. 72.4 vs. 68.0 %, p = 0.22), and 5-year OS (60.8 vs. 64.0 vs. 62.2 %, p = 0.69) when compared to overweight subjects and those with normal BMIs, respectively. Likewise, individuals with high BSA had similar outcomes as those with normal BSA (66.2 vs. 63.6 %, p = 0.64 for 3-year RFS, 70.3 vs. 68.6 %, p = 0.62 for 5-year CSS, and 64.5 vs. 61.9 %, p = 0.48 for 5-year OS). In Cox models, advanced age, male gender, stage III disease, and poor performance status correlated with inferior RFS, CSS, and OS, but BMI and BSA did not.Obesity as measured by either BMI or BSA was not associated with differences in outcomes in stage II and III colon cancer.

Background The creation of surgical skin incisions has historically been performed using a cold scalpel. The use of electrocautery for this purpose has been controversial with respect to patient safety and surgical efficacy. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to compare skin incisions made by electrocautery and a scalpel. Data sources A systematic electronic literature search was performed using 2 electronic databases (MEDLINE and PubMed), and the methodological quality of included publications was evaluated. Six RCTs were identified comparing electrocautery (n = 606) and a scalpel (n = 628) for skin incisions. Conclusions No significant difference in wound infection rates or scar cosmesis was identified between the treatment groups. Electrocautery significantly reduced the incision time and postoperative wound pain. A trend toward less incisional blood loss from skin incisions made with electrocautery was noted. Electrocautery is a safe and effective method for performing surgical skin incisions.

The drug fluorouracil (5-FU) is a widely used antimetabolite chemotherapy in the treatment of colorectal cancer. The gene uridine monophosphate synthetase (UMPS) is thought to be primarily responsible for conversion of 5-FU to active anticancer metabolites in tumor cells. Mutation or aberrant expression of UMPS may contribute to 5-FU resistance during treatment. We undertook a characterization of UMPS mRNA isoform expression and sequence variation in 5-FU-resistant cell lines and drug-naive or -exposed primary and metastatic tumors. We observed reciprocal differential expression of two UMPS isoforms in a colorectal cancer cell line with acquired 5-FU resistance relative to the 5-FU-sensitive cell line from which it was derived. A novel isoform arising as a consequence of exon skipping was increased in abundance in resistant cells. The underlying mechanism responsible for this shift in isoform expression was determined to be a heterozygous splice site mutation acquired in the resistant cell line. We developed sequencing and expression assays to specifically detect alternative UMPS isoforms and used these to determine that UMPS was recurrently disrupted by mutations and aberrant splicing in additional 5-FU-resistant colorectal cancer cell lines and colorectal tumors. The observed mutations, aberrant splicing and downregulation of UMPS represent novel mechanisms for acquired 5-FU resistance in colorectal cancer.

Objective Systematic reviews were performed to assess methods of teaching the evidence-based medicine (EBM) process and determine which format or what components of journal club appear to be most effective in teaching critical appraisal skills to surgical residents and have the highest user satisfaction. Design MEDLINE, Embase, Web of Science, AMED, PsychINFO, PubMed, Cochrane Library, and Google scholar were searched to identify relevant articles. To be included, studies had to provide details about the format of their EBM curriculum or journal club and report on the effectiveness or participant satisfaction. Potentially relevant articles were independently reviewed by 2 authors and data were extracted on separate data forms. Results Seven studies met the inclusion criteria for assessment of teaching EBM and 8 studies (including 3 in the EBM systematic review) met criteria for assessment of journal club format. Overall, study quality was poor. Only 2 studies were randomized controlled trials. Five were before-after studies, which showed significant improvement in critical appraisal skills or statistical knowledge following an EBM course or journal club. The 2 randomized controlled trials (RCTs) compared teaching EBM or critical appraisal skills in lecture format or journal club to online learning. There was no significant difference in mean scores in 1 study whereas the other reported significantly better scores in the journal club format. Four studies reported high participant satisfaction with the EBM course or journal club format. Conclusions There is some evidence that courses with or without the addition of journal clubs lead to improved knowledge of the EBM process although the impact on patient care is unknown. Journal clubs seem to be the preferred way of teaching critical appraisal skills but while some components of journal clubs are favored by participants, it remains unclear which elements are most important for resident learning.

PURPOSE: In a strategy aimed to improve perioperative and operative management of rectal cancer in British Columbia (BC), a series of educational events were provided for BC surgeons, radiation oncologists, and pathologists including teaching on the use of preoperative radiation, surgical technique with total mesorectal excision (TME), and pathology reporting. Seminars were offered during 2002 and 2003 each over 2 days with documented attendance from 30 hospitals in the province. We wished to determine whether frequency of preoperative radiation and TME surgery changed on a population level after the rectal cancer education courses in 2002 and 2003. METHODS: All patients were referred to the BC Cancer Agency, the only center for radiation in BC. Treatments and data were abstracted from the Colorectal Cancer Outcomes Unit database. Patients with resected stage I to III rectal cancer were included who were diagnosed before (2000-2001) and after (2004) the education courses. We used changes from 2000 to 2001 to reflect effects of sporadic continued medical education (CME) compared with effects of formal systematic provincial education courses (changes from 2001 to 2004). RESULTS: A total of 778 eligible patients were included from 2000 (n = 264), 2001 (n = 202), and 2004 (n = 312). The percentage of stage III patients was similar in the 3 time periods. The use of preoperative radiation therapy increased significantly over time, 43% (114/264), 56% (113/202), and 86% (268/312) (P < .0001). TME use also increased significantly, 35%, 44%, and 71% (P < .0001). CONCLUSIONS: The implementation of guidelines for the use of preoperative radiation and TME by formal systematic provincial education courses for surgeons, radiation oncologists, and pathologists resulted in significant improvements in rectal cancer management on a provincial level. Such programs may be more effective than "sporadic" CME, particularly in multidisciplinary and complex care settings like adjuvant rectal cancer therapy.

Clinical evaluation alone is still considered adequate by many clinicians who treat patients with appendicitis. The impact of computed tomography (CT) on clinical outcomes remains unclear, and there is no consensus regarding the appropriate use of CT in these patients. We sought to evaluate the impact of abdominal CT on the clinical outcomes of patients presenting with suspected appendicitis.We conducted a systematic review of the literature to identify studies that examined clinical outcomes related to the use of abdominal CT in the diagnosis of acute appendicitis. Inclusion criteria were studies of adult patients with suspected appendicitis that evaluated the impact of abdominal CT on negative appendectomy rates, perforation rates or time to surgery. Two independent investigators reviewed all titles and abstracts and extracted data from 28 full-text articles. Statistical analysis was conducted using Review Manager 5.0.10 software.The negative appendectomy rate was 8.7% when using CT compared with 16.7% when using clinical evaluation alone (p0.001). There was also a significantly lower negative appendectomy rate during the CT era compared with the pre-CT era (10.0% v. 21.5%, p0.001). Time to surgery was evaluated in 10 of the 28 studies, 5 of which demonstrated a significant increase in the time to surgery with the use of CT. Appendiceal perforation rates were unchanged by the use of CT (23.4% in the CT group v. 16.7% in the clinical evaluation group, p = 0.15). Similarly, the perforation rate during the CT era was not significantly different than that during the pre-CT era (20.0% v. 19.6%, p = 0.74).This meta-analysis supports the hypothesis that the use of preoperative abdominal CT is associated with lower negative appendectomy rates. The use of CT in the absence of an expedited imaging protocol may delay surgery, but this delay is not associated with increased appendiceal perforation rates. Routine CT in all patients presenting with suspected appendicitis could reduce the rate of unnecessary surgery without increasing morbidity.

Objective: To determine if screening mammography produced the expected increase in the incidence of early-stage breast cancer and reduced the expected incidence of late-stage breast cancer in women 40 years of age or older. Design: Population-based observation study using a before and after cohort time series design. Data Sources: 1) National Health Interview Survey; 2) Surveillance, Epidemiology and End Results (SEER) data; 3) United States Census. Results: The introduction of screening mammography in the United States has been associated with a doubling in the number of cases of early-stage breast cancer detected each year from 112 to 234 cases per 100 000 women — an absolute increase of 122 cases per 100 000 women. Concomitantly, the rate at which women present with late-stage cancer has decreased from 102 to 94 cases per 100 000 women — an absolute decrease of 8 cases per 100 000 women. With the assumption of a constant underlying disease burden, it was estimated that only 8 of the 122 additional early-stage cancers diagnosed would progress to advanced disease. After excluding the transient excess incidence associated with hormone replacement therapy and adjusting for trends in the incidence of breast cancer among women younger than 40 years old, it was estimated that breast cancer was overdiagnosed (i.e., tumours were detected on screening that would never have led to clinical symptoms) in 70 000 women in 2008 and 1.3 million women in the past 30 years. Conclusion: Despite substantial increases in the number of early-stage breast cancer detected, screening mammography has only marginally reduced the rate at which women present with late-stage cancer.

The surgical circumferential resection margin in total mesorectal excision surgery is defined by the relationship of the tumor to the mesorectal fascia. Patients with anticipated tumor invasion of the mesorectal fascia receive neoadjuvant therapy to downstage/downsize the tumor and to obtain tumor-free resection margins.Tumor relationship to the mesorectal fascia is accurately determined by MRI. Compared with MRI, multidetector-row computed tomography is more widely available, faster, less costly, and provides the ability to simultaneously assess the liver, peritoneum, and retroperitoneum for metastases.The objective of this study was to compare the accuracy of multidetector-row CT with conventional MRI in diagnosis of rectal cancer invasion of the mesorectal fascial envelope.During a 2-year period, all patients were enrolled in this study who had biopsy-proven rectal carcinoma and were referred, as a part of the routine preoperative staging workup, for a CT scan of the abdomen and pelvis and also an MRI of the pelvis.All examinations were reviewed independently by 2 radiologists who were blinded from one another, from the findings of the other modality, and from clinical information. Both observers were dedicated abdominal radiologists who are experienced in reading pelvic CT and MRI. Categorical agreement between MRI and multidetector-row CT for all the evaluated parameters of the tumor position, mesorectal fascia, and lymph nodes, as well as the interobserver agreement between CT and MRI, was determined by the intraclass correlation weighted kappa statistic to measure the data set's consistency.Among the study's 92 patients, the tumor characteristics suggested by multidetector-row CT agreed with those of MRI, with a weighted kappa ranging from 0.488 to 0.748 for the first reader and 0.577 to 0.800 for the second reader. Interobserver agreement ranged from 0.506 to 0.746.Agreement regarding mesorectal fascia characteristics differed significantly between multidetector-row CT and MRI, depending on the level of assessment. In the distal rectum, agreement was 0.207 for the first reader and 0.385 for the second reader. In the mid rectum, agreement was 0.420 and 0.527, respectively, and in the proximal rectum agreement was 0.508 and 0.520. Interobserver agreement was 0.737 at the distal level and 0.700 at the mid and proximal levels. Agreement regarding measurement of the distance from the tumor to the mesorectal fascia was 0.425 for the first reader and 0.723 for the second reader, with interobserver agreement of 0.766. Agreement in assessment of the number of lymph nodes ranged from 0.743 to 0.787 for the first reader and 0.754 to 0.840 for the second reader. Interobserver agreement ranged from 0.779 to 0.841. Agreement in assessment of the size of the lymph nodes ranged from 0.540 to 0.830 for the first reader and 0.850 to 0.940 for the second reader. Interobserver agreement ranged from 0.900 to 0.920. Agreement in assessment of the distance from nodes to the mesorectal fascia was 0.320 for the first reader and 0.401 for the second reader, with interobserver agreement of 0.950.The results of this study differ from previously published data by demonstrating substantial agreement between readers in multidetector-row CT assessment of the tumor, mesorectal fascia, and lymph nodes. With the exceptions of mesorectal fascia in the distal rectum and the distance from the nodes to mesorectal fascia, other evaluated parameters were assessed with moderate and substantial agreement between multidetector-row CT and MRI. However, our findings suggest that multidetector-row CT does not correlate well enough with MRI findings to replace it in rectal cancer staging.

Purpose This study was designed to review the clinical and pathologic findings, treatment, and outcomes of patients who have a cancer that complicates perianal Crohn's disease. Methods Charts of patients who had documented perianal Crohn's disease and a pathologic diagnosis of anal carcinoma were reviewed. Results There were 14 patients (6 men; mean age, 49 years) who had evidence of perianal Crohn's disease (mean, 6.9 (range, 1-20) years) before their cancer diagnosis. The diagnosis often was delayed despite increasing pain, multiple biopsies, and imaging studies. Ten patients had preoperative diagnoses of cancer; however, none of the eight magnetic resonance imaging studies were diagnostic. There were 11 adenocarcinomas (8 mucinous or colloid subtypes) and 3 squamous-cell carcinomas. Treatment included abdominoperineal resections plus chemotherapy in 12, and radiation and a defunctioning stoma in 1 patient. Of the 12 who had an abdominoperineal resection, 3 had posterior vaginectomies and rectus flap reconstructions. At last follow-up (mean, 41 (median, 22) months), five patients were alive without disease, five were alive with disease, and four had died. Conclusions Physicians should have a high level of suspicion of cancer in patients with longstanding perianal Crohn's disease who have a change in symptoms. In this series, patients who were diagnosed preoperatively and treated with multimodality therapy had better outcomes.

Colorectal cancer (CRC) is the second leading cause of cancer-related death in the USA. Surgery is the primary treatment for most patients with CRC. Over the past 15 years, minimally invasive techniques for colorectal surgery have been developed. There is growing evidence that these techniques have significant advantages in short-term outcomes (e.g., postoperative pain and length of hospital stay) with similar long-term recurrence and overall survival. While transanal local excision has been shown to be inferior to radical resection for early rectal cancer, transanal endoscopic microsurgery (TEM) is a minimally invasive technique that appears to facilitate local excision in appropriate patients. TEM combined with radiotherapy has demonstrated promising early results and is currently being investigated in clinical trials as a potential alternative to radical surgery. We summarize the current literature on these minimally invasive approaches to CRC.

Spinal epidural abscess is an uncommon but highly morbid illness. While it usually afflicts older, immunocompromised patients, this condition has been reported as a result of intestinal perforation in the setting of inflammatory bowel disease. Two cases of spinal epidural abscess in patients with inflammatory bowel disease are reported: one in a patient with Crohn’s disease and one in a patient with ulcerative colitis after restorative proctocolectomy.

Although there is enthusiasm for nonoperative management of anal fissures, most trials have been of short duration (6–8 weeks) and long-term outcome is unknown. The purpose of this study was to assess long-term outcome in two cohorts of patients who had participated in a randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure. Between February 1997 and October 1998, 82 patients with chronic anal fissure were accrued and randomized to 0.25 percent nitroglycerin ointment t.i.d. or lateral internal sphincterotomy. In 2004, a telephone survey of trial participants was conducted to determine symptom recurrence, the need for further medical and/or surgical treatment, and patient satisfaction. Furthermore, patients were assessed for symptoms of fecal incontinence using the Jorge and Wexner Fecal Incontinence Score and the Fecal Incontinence Quality of Life questionnaire. Overall, 51 of the original 82 patients (62 percent, 27 nitroglycerin, 24 lateral internal sphincterotomy) completed our survey. Mean follow-up was 79 (±1) months. Sphincterotomy patients were less likely to have experienced fissure symptoms within the past year (0 vs. 41 percent; P = 0.0004) and were less likely to require subsequent surgical treatment (0 vs. 59 percent; P

Endorectal ultrasound (ERUS) is used to preoperatively assess locoregional stage in patients with rectal neoplasms. This study evaluates the accuracy of ERUS in determining the T stage of rectal neoplasms treated by transanal endoscopic microsurgery (TEM).All patients in the St Paul's Hospital TEM database were evaluated and excluded if they had been treated with neoadjuvant therapy. ERUS results were compared with gold-standard postoperative histopathology reports. Tumor height from anal verge was measured by ERUS and endoscopic techniques.Fifty-three patients were eligible to participate in the study. A Friedman test demonstrated significant difference in the T stage between ERUS and the histopathology reports (P.001). The tumor height measured by ERUS is significantly higher than the height measured by endoscopy (P.05).This study confirms that ERUS often overstages rectal neoplasms and suggests that ERUS findings should not preclude TEM in clinically appropriate patients.

This study was designed to determine the outcome of patients with Crohn’s disease and indeterminate colitis who have an ileal pouch-anal anastomosis. Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn’s disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35-question survey mailed to all patients with a functioning pouch of at least six months duration. Pouch complications were significantly more common in patients with Crohn’s disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn’s disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn’s disease, multivariate analysis revealed that the pathologist’s initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn’s disease were independently associated with pouch failure. The functional results in patients with Crohn’s disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis. Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one-half of patients with Crohn’s disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn’s disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn’s disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch-anal anastomosis is an acceptable alternative for patients with indeterminate colitis.