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Background Ligation of the intersphincteric fistula tract (LIFT) was developed to treat transsphincteric anal fistulas. The aftermath of a failed LIFT has not been well documented. Methods Retrospective chart review of LIFT procedure for transsphincteric anal fistula between March 2012 and September 2016. Results 53 patients with LIFT procedure were identified, 20 (37.7%) had persistent fistula with median followup of 4 months. Following LIFT, recurrence of fistula was transsphincteric (75%) or intersphincteric (25%) (p = NS). Persistent transsphincteric fistulas after LIFT were treated with seton (71.4%) followed by advancement flap (20%) or fistulotomy (50%). Of the recurrent intersphincteric fistulas, 50% underwent seton placement followed by fistulotomy, or advancement flap. Of the patients who underwent surgery after failed LIFT, 50% have had resolution of the fistula; 31.7% are still undergoing treatment. Conclusion Patients who underwent surgery after failed LIFT had 50% healing with placement of seton followed by fistulotomy or rectal advancement flap.

Hemorrhoid banding is an established treatment for symptomatic internal hemorrhoids with proven efficacy, low cost, and limited discomfort. Although the costs and quality of life following individual banding treatments have been investigated, little is known about cumulative cost and quality of life from sequential banding therapy or how these cumulative costs compare to surgical therapy.This study aimed to determine the cost-effectiveness of sequential hemorrhoid banding therapy.A retrospective review of historic banding treatment patterns was performed. Cost estimates and quality-of-life predictions were applied to observed treatment patterns in a decision-analytic cost-effectiveness model to compare sequential banding therapy with hypothetical surgical intervention.A retrospective billing record review for patients treated in a colorectal specialty clinic between 2012 and 2017 was performed.Patients initially treated with banding therapy for symptomatic internal hemorrhoids were included.The primary outcomes measured were hemorrhoid banding treatment patterns, cost-effectiveness, and net monetary benefit.Treatment of 2026 patients undergoing hemorrhoid banding identified 94% resolution with sequential banding and 6% requiring delayed surgical intervention. Average cumulative estimated cost for banding therapy was $723 (range, $382-$4430) per patient with an average quality-of-life deficit of -0.00234 (range, -0.00064 to -0.02638) quality-adjusted life-years. Estimates for hypothetical hemorrhoid artery ligation, stapled hemorrhoidopexy, or surgical hemorrhoidectomy found significantly higher cost (3.15×, 4.39×, and 2.75× more expensive) and a significantly worse quality-of-life deficit (1.55×, 5.64×, and 9.45× worse). For patients with persistent disease, continued sequential banding remained the dominant cost-effective therapy.This cost-effectiveness model relies on a retrospective review of billing records with estimated cost and quality of life.Hemorrhoid banding is a valuable treatment modality with favorable cost-effectiveness. The majority of patients selected for banding find resolution without surgery. For patients with persistent disease, further banding procedures remain cost-effective compared with delayed surgical therapy. See Video Abstract at http://links.lww.com/DCR/A982.UN ANÁLISIS DE COSTO-EFECTIVIDAD: La banda para hemorroides es un tratamiento establecido para las hemorroides internas sintomáticas con eficacia comprobada, bajo costo y malestar limitado. Si bien se han investigado los costos y la calidad de vida después de los tratamientos de bandas individuales, se sabe poco sobre el costo acumulativo y la calidad de vida de la terapia de bandas secuencial o cómo estos costos acumulativos se comparan con la terapia quirúrgica.Determinar el costo-efectividad de la terapia secuencial de bandas hemorroidales. DISEÑO:: Se realizó una revisión retrospectiva de la historia de los patrones de tratamiento con bandas. Las estimaciones de costos y las predicciones de la calidad de vida se aplicaron a los patrones de tratamiento observados en un modelo analítico de costo-efectividad para comparar la terapia de bandas secuencial con la intervención quirúrgica hipotética.Revisión retrospectiva de los registros de facturación de los pacientes tratados en una clínica de especialidad colorrectal entre 2012 y 2017.Pacientes tratados inicialmente con terapia de bandas para hemorroides internas sintomáticas.Patrones de tratamiento con bandas de hemorroides, costo-efectividad y beneficio monetario neto.El tratamiento de 2026 pacientes con bandas identificó una resolución del 94% con bandas secuenciales y el 6% requirió una intervención quirúrgica tardía. El costo promedio acumulado estimado para la terapia de banda fue de $ 723 (Rango: $382-$4430) por paciente con un déficit de calidad de vida promedio de -0.00234 (Rango: -0.00064 a -0.02638) años de vida ajustados por calidad. Las estimaciones para la hipotética ligadura de la arteria hemorroidal, la hemorroidopexia con grapas o la hemorroidectomía quirúrgica encontraron un costo significativamente mayor (3.15×, 4.39×, 2.75× más caro) y un déficit de la calidad de vida significativamente peor (1.55×, 5.64×, 9.45× peor). Para los pacientes con enfermedad persistente, la colocación de bandas secuenciales continuas siguió siendo la terapia rentable dominante.Este modelo de costo-efectividad se basa en una revisión retrospectiva de los registros de facturación con el costo y la calidad de vida estimados.Las bandas de hemorroides son una valiosa modalidad de tratamiento con una favorable relación costo-efectividad. La mayoría de los pacientes seleccionados para terapia con bandas encuentran resolución sin cirugía. Para los pacientes con enfermedad persistente, los procedimientos de colocación de bandas adicionales siguen siendo rentables en comparación con el tratamiento quirúrgico tardío. Vea el Resumen del video en http://links.lww.com/DCR/A982.

Definitive surgery with total mesorectal excision is the mainstay of treatment for locally advanced rectal cancer. Multimodality therapy improves long-term survival. Current standards advise neoadjuvant chemoradiation followed by radical surgery and adjuvant chemotherapy. Nationally, compliance with adjuvant chemotherapy is only 32%. New research evaluates the effectiveness of total neoadjuvant therapy: complete chemotherapy and chemoradiation before surgery.The aim of this study is to determine the favored treatment for locally advanced rectal cancer by comparing the cost-effectiveness of total neoadjuvant therapy and the current standard of care.Decision analytical modeling using long-term costs and 5-year disease-free survival was performed to determine the cost-effectiveness after total neoadjuvant therapy and the current standard of care. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters.Centers for MedicareMedicaid Services billing data perspective was adopted and outcomes modeled according to local and national databases and literature consensus.Adult patients with stage II or III rectal cancer were selected.Cost-effectiveness in disease-free life-years, incremental cost-effectiveness ratio, and net monetary benefit were determined over a 5-year posttreatment period. The favored strategy was determined based on cost-effectiveness and sensitivity analyses.Cost-effectiveness for total neoadjuvant therapy was 40,708 $/life-year, and, for conventional therapy, cost-effectiveness was 44,248 $/life-year. Sensitivity analysis showed that, for an estimated total neoadjuvant therapy completion rate of 90%, total neoadjuvant therapy would remain the dominant strategy for any adjuvant chemotherapy completion rate of less than 93%.The samples used to calculate completion rates are small, and survival probabilities are based on existing literature, local database values, and consensus estimates. The model encompasses a 5-year time period from diagnosis.Cost-effectiveness analysis shows that a strategy of total neoadjuvant therapy followed by radical surgery is favored over the current standard of care for locally advanced rectal cancer. Sensitivity analysis shows that a low rate of adjuvant chemotherapy administration plays a key role in decreasing the cost-effectiveness of the current standard of care. See Video Abstract at http://links.lww.com/DCR/A942.

The need for reoperation for diverticulitis may become necessary for a range of conditions. Surgeons will most commonly encounter these conditions in an elective setting with planned cases for ostomy reversal, however, recurrence of acute disease after sigmoid resection also occurs with a degree of regularity. A suspected recurrence should prompt a workup for alternative conditions, such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). Reoperation in the emergent setting may be necessary for both recurrent diverticulitis as well as complications from earlier procedures. Attention to technical details improves outcome of both elective and emergent reoperations. The operative plan should be individualized to optimize patient outcomes. This discussion will review necessary details to enhance the chance of successful outcomes. Details for the management of some of these issues (problems common to colon and rectal surgery in general, e.g., anastomotic leaks, stoma complications, and fistulas) are discussed elsewhere in this publication. Some conclusions are based on the extrapolation of data from more generalized reviews because the literature on reoperative diverticular surgery is limited.

Cancer of the colon and rectum is extremely common in the Western hemisphere. The etiopathogenesis of colorectal cancer is an intertwined play of several genetic and environmental factors to which an individual is exposed to during the lifetime. The predominance of one factor over another decides the timing of development of this cancer with respect to the individual’s age. Familial syndromes like Lynch syndrome and familial adenomatous polyposis predispose an individual to cancer early in their lifespan since they carry the genetic mutation. A sporadic cancer, on the other hand, follows a very interesting and often predictable path from a polyp to carcinoma. There are three such pathways which the colonic epithelium may undertake toward the development of cancer. Each of the pathways has its own unique set of genotypic and phenotypic expression which needs to be understood well to accomplish our ultimate goal for prevention of colorectal cancer.

Background The aim of this study was to assess the rate of permanent diversion in patients undergoing coloanal anastomosis after neoadjuvant therapy for rectal cancer. Methods We performed a retrospective review of patients with rectal cancer who underwent a total mesorectal excision of a tumor within 9 cm of the anal verge. Results There were 201 patients who underwent resection with coloanal anastomosis, with a mean follow-up period of 51 months. The average tumor distance from the anal verge was 7 cm (range, 4–9 cm). Neoadjuvant therapy was administrated in 145 patients, 47 had no radiation, and 9 received radiation postoperatively. Thirty-two patients (16%) had long-term complications including incontinence, fistulas, and strictures. Twenty-five patients (12%) had recurrent disease, 16 of these were local recurrence. The total rate of permanent diversion was 29 (14%). Reasons for diversion included local recurrence in 12 patients (6%), complications in 10 patients (5%), and poor function in 7 patients (3%). Conclusions Poor bowel function, late complications, and local recurrence all contribute to permanent diversion after a coloanal anastomosis. Neoadjuvant therapy in conjunction with a total mesorectal excision and coloanal anastomosis leads to acceptably low permanent diversion rates in the vast majority of patients.

Colorectal cancer (CRC) constitutes the second leading cause of death from cancer in the United States. Increased screening for CRC have been associated with a decreased incidence in the past two decades. Continued efforts are necessary to maintain this trend. Appropriate risk stratification of individuals and compliance with recommended screening strategies are important. Colonoscopy continues to play an important role in screening; however, several different screening options are available for average-risk individuals. This article reviews the current options open to physicians to adequately screen patients for CRC based on inherit risks.

Background:There are no studies of rurality, and other determinants of colorectal cancer (CRC) stage at diagnosis with population-based data from the Midwest. Methods: This retrospective study identified, incident CRC patients, aged 19 years and older, from 1998-2003 Nebraska Cancer Registry (NCR) data. Using federal Office of Management and Budget classifications, we grouped patients by residence in metropolitan, micropolitan nonmetropolitan, or rural nonmetropolitan counties (non-core based statistical areas). In univariate and multivariate logistic regression analyses, we examined the association of the county classification and of other determinants with early (in situ/local) versus late (regional/distant) stage at CRC diagnosis. Results: Of the 6,561 CRC patients identified, 45% were from metropolitan counties, 24% from micropolitan nonmetropolitan counties and 31% from rural nonmetropolitan counties, with 32%, 38%, and 33%, respectively, being diagnosed at an early stage. Multivariate analysis showed micropolitan nonmetropolitan residents were significantly more likely than rural nonmetropolitan residents to be diagnosed at an early stage (adjusted OR, 1.22; 95% CI: 1.05-1.42, P < .05). However, rural nonmetropolitan and metropolitan residents did not significantly differ in the likelihood of early diagnosis. Residents with Medicare rather than those with private insurance (P < .0001), married rather than unmarried residents (P < .01), and residents with rectal cancer rather than those with colon cancer (P < .0001) were more likely to be diagnosed at an early stage. Conclusions: Early CRC diagnosis needs to be increased in rural (non-core) non-metropolitan residents, unmarried residents, and those with private insurance.

In the United States, colorectal cancer (CRC) is the third most common cancer diagnosed among men and women and the second leading cause of death from cancer. CRC largely can be prevented by the detection and removal of adenomatous polyps, and survival is significantly better when CRC is diagnosed while still localized. In 2006 to 2007, the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology came together to develop consensus guidelines for the detection of adenomatous polyps and CRC in asymptomatic average-risk adults. In this update of each organization's guidelines, screening tests are grouped into those that primarily detect cancer early and those that can detect cancer early and also can detect adenomatous polyps, thus providing a greater potential for prevention through polypectomy. When possible, clinicians should make patients aware of the full range of screening options, but at a minimum they should be prepared to offer patients a choice between a screening test that is effective at both early cancer detection and cancer prevention through the detection and removal of polyps and a screening test that primarily is effective at early cancer detection. It is the strong opinion of these 3 organizations that colon cancer prevention should be the primary goal of screening.

PURPOSE: Children with familial adenomatous polyposis have a greater mortality and morbidity in the first decade of life compared with the general population. Some children with a more severe disease phenotype present early with colorectal adenomata and may require colectomy at an early age. We present our multidisciplinary clinic experience with familial adenomatous polyposis in children younger than age ten years at the time of presentation. METHODS: A cross-sectional analysis was performed on all patients with suspected or confirmed familial adenomatous polyposis presenting in the first decade of life and followed by the multidisciplinary Pediatric Hereditary Polyposis Clinic at our institutions. Analysis included demographics, clinical presentation and course, gene mutation testing, endoscopic-histologic findings, and surgical outcome. RESULTS: Twenty-two children (11 males) presented with suspected or confirmed familial adenomatous polyposis. Two were discharged from follow-up after negative adenomatous polyposis coli gene mutation testing. The rest underwent annual hepatoblastoma surveillance through age ten years with negative findings. Twelve patients presented with symptoms: six had de novo familial adenomatous polyposis. Seven had gastrointestinal hemorrhage and went on to colonoscopy. Four patients with adenomatous polyposis coli gene mutation at codon 1309 were referred for colectomy before age ten years. Referral to colectomy was earlier in patients with 1309 mutation and with de novo familial adenomatous polyposis. CONCLUSIONS: Children with familial adenomatous polyposis younger than age ten years may present presymptomatically for disease surveillance. Familial adenomatous polyposis with adenomatous polyposis coli gene mutation at codon 1309 entails a risk of a more aggressive phenotype; early colectomy may be indicated in children harboring this gene mutation.

In 1998, the American Cancer Society (ACS) set a challenge goal for the nation to reduce cancer incidence by 25% over the period between 1992 and 2015. This report examines the trends in cancer incidence between 1992 and 2004. Trends were calculated using data on incident malignant cancer cases from the Surveillance, Epidemiology, and End Results (SEER) Registry. Delay-adjusted incidence trends for all cancer sites; all cancer sites without prostate cancer included; all cancer sites stratified by gender, age, and race; and for 20 selected cancer sites are presented. Over the first half of the ACS challenge period, overall cancer incidence rates have declined by about 0.6% per year. The greatest overall declines were observed among men and among those aged 65 years and older. The pace of incidence reduction over the first half of the ACS challenge period was only half that necessary to put us on target to achieve the 25% cancer incidence reduction goal in 2015. New understandings of preventable factors are needed, and new efforts are also needed to better act on our current knowledge about how we can prevent cancer, especially by continuing to reduce tobacco use and beginning to reverse the epidemic of obesity.

Adhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the length of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm.Twenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured.All 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p = 0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p = 0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p = 0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively).When consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.

Patients with resected colorectal cancer are at risk for recurrent cancer and metachronous neoplasms in the colon. This joint update of guidelines by the American Cancer Society and the US Multi-Society Task Force on Colorectal Cancer addresses only the use of endoscopy in the surveillance of these patients. Patients with endoscopically resected Stage I colorectal cancer, surgically resected Stages II and III cancers, and Stage IV cancer resected for cure (isolated hepatic or pulmonary metastasis) are candidates for endoscopic surveillance. The colorectum should be carefully cleared of synchronous neoplasia in the perioperative period. In nonobstructed colons, colonoscopy should be performed preoperatively. In obstructed colons, double-contrast barium enema or computed tomography colonography should be performed preoperatively, and colonoscopy should be performed 3 to 6 months after surgery. These steps complete the process of clearing synchronous disease. After clearing for synchronous disease, another colonoscopy should be performed in 1 year to look for metachronous lesions. This recommendation is based on reports of a high incidence of apparently metachronous second cancers in the first 2 years after resection. If the examination at 1 year is normal, then the interval before the next subsequent examination should be 3 years. If that examination is normal, then the interval before the next subsequent examination should be 5 years. Shorter intervals may be indicated by associated adenoma findings (see "Guidelines for Colonoscopy Surveillance After Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society"). Shorter intervals also are indicated if the patient's age, family history, or tumor testing indicate definite or probable hereditary nonpolyposis colorectal cancer. Patients undergoing low anterior resection of rectal cancer generally have higher rates of local cancer recurrence compared with those with colon cancer. Although effectiveness is not proven, performance of endoscopic ultrasound or flexible sigmoidoscopy at 3- to 6-month intervals for the first 2 years after resection can be considered for the purpose of detecting a surgically curable recurrence of the original rectal cancer.

Adenomatous polyps are the most common neoplastic findings discovered in people who undergo colorectal screening or who have a diagnostic work-up for symptoms. It was common practice in the 1970s for these patients to have annual follow-up surveillance examinations to detect additional new adenomas and missed synchronous adenomas. As a result of the National Polyp Study report in 1993, which showed clearly in a randomized design that the first postpolypectomy examination could be deferred for 3 years, guidelines published by a gastrointestinal consortium in 1997 recommended that the first follow-up surveillance take place 3 years after polypectomy for most patients. In 2003 these guidelines were updated and colonoscopy was recommended as the only follow-up examination, stratification at baseline into low risk and higher risk for subsequent adenomas was suggested. The 1997 and 2003 guidelines dealt with both screening and surveillance. However, it has become increasingly clear that postpolypectomy surveillance is now a large part of endoscopic practice, draining resources from screening and diagnosis. In addition, surveys have shown that a large proportion of endoscopists are conducting surveillance examinations at shorter intervals than recommended in the guidelines. In the present report, a careful analytic approach was designed to address all evidence available in the literature to delineate predictors of advanced pathology, both cancer and advanced adenomas, so that patients can be stratified more definitely at their baseline colonoscopy into those at lower risk or increased risk for a subsequent advanced neoplasia. People at increased risk have either 3 or more adenomas, high-grade dysplasia, villous features, or an adenoma 1 cm or larger in size. It is recommended that they have a 3-year follow-up colonoscopy. People at lower risk who have 1 or 2 small (1 cm) tubular adenomas with no high-grade dysplasia can have a follow-up evaluation in 5-10 years, whereas people with hyperplastic polyps only should have a 10-year follow-up evaluation, as for average-risk people. There have been recent studies that have reported a significant number of missed cancers by colonoscopy. However, high-quality baseline colonoscopy with excellent patient preparation and adequate withdrawal time should minimize this and reduce clinicians concerns. These guidelines were developed jointly by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society to provide a broader consensus and thereby increase the use of the recommendations by endoscopists. The adoption of these guidelines nationally can have a dramatic impact on shifting available resources from intensive surveillance to screening. It has been shown that the first screening colonoscopy and polypectomy produces the greatest effects on reducing the incidence of colorectal cancer in patients with adenomatous polyps.

Patients with resected colorectal cancer are at risk for recurrent cancer and metachronous neoplasms in the colon. This joint update of guidelines by the American Cancer Society (ACS) and US Multi-Society Task Force on Colorectal Cancer addresses only the use of endoscopy in the surveillance of these patients. Patients with endoscopically resected Stage I colorectal cancer, surgically resected Stage II and III cancers, and Stage IV cancer resected for cure (isolated hepatic or pulmonary metastasis) are candidates for endoscopic surveillance. The colorectum should be carefully cleared of synchronous neoplasia in the perioperative period. In nonobstructed colons, colonoscopy should be performed preoperatively. In obstructed colons, double contrast barium enema or computed tomography colonography should be done preoperatively, and colonoscopy should be performed 3 to 6 months after surgery. These steps complete the process of clearing synchronous disease. After clearing for synchronous disease, another colonoscopy should be performed in 1 year to look for metachronous lesions. This recommendation is based on reports of a high incidence of apparently metachronous second cancers in the first 2 years after resection. If the examination at 1 year is normal, then the interval before the next subsequent examination should be 3 years. If that colonoscopy is normal, then the interval before the next subsequent examination should be 5 years. Shorter intervals may be indicated by associated adenoma findings (see Postpolypectomy Surveillance Guideline). Shorter intervals are also indicated if the patient's age, family history, or tumor testing indicate definite or probable hereditary nonpolyposis colorectal cancer. Patients undergoing low anterior resection of rectal cancer generally have higher rates of local cancer recurrence, compared with those with colon cancer. Although effectiveness is not proven, performance of endoscopic ultrasound or flexible sigmoidoscopy at 3- to 6-month intervals for the first 2 years after resection can be considered for the purpose of detecting a surgically curable recurrence of the original rectal cancer.

Our purpose is to focus attention on the cancer family history, coupled with an understanding of the natural history and extracolonic tumor spectrum of familial adenomatous polyposis (FAP), through a family study. This family report provides an example of how colorectal cancer (CRC) can be prevented by knowledgeable gastroenterologists and colorectal surgeons who educate and compassionately counsel members of high-risk families so that their compliance with diagnostic screening and, ultimately, with protection through prophylactic colectomy, is achieved. A working pedigree of this extended family was constructed through interviews with the proband, followed by questionnaires sent to all primary and secondary relatives. Appropriately signed permission forms enabled us to secure pertinent medical and pathology records in order to ensure accuracy of historical information. Integral extracolonic tumors included medulloblastoma, papillary thyroid carcinoma, hepatoblastoma, and desmoid tumors. We conclude that, due in part to improved longevity as a result of being spared CRC, several family members have developed certain FAP integral extracolonic cancers.

Recent advances in the understanding of the molecular biology of colorectal cancer have resulted in many new implications for surgeons. To continue providing sound patient care, surgeons must familiarize themselves with associated issues that include genetic counseling and its role in patient and family management. Issues related to genetic counseling are reviewed in this article. Recommendations for surgical therapy and surveillance methods are summarized for each of the hereditary syndromes. Failure to use these patient management tools in an effective way may be a source of future litigation.

PURPOSE: Anal sphincter replacement offers a new treatment option for patients with severe refractory fecal incontinence or for those who require abdominoperineal resection for localized malignancy. The purpose of this study was to review the current status of anal sphincter replacement, formulate a consensus statement regarding its current use, and outline suggestions for future development. METHODS: Four areas of interests were selected: indications for sphincter replacement, continence scoring and quality of life, choice of therapy, and dissemination of new technology. A questionnaire regarding these issues was developed and circulated to working party members; its results served as the basis for this consensus document. RESULTS: Both electrically stimulated skeletal muscle neosphincter and artificial anal sphincter are options for patients with end-stage fecal incontinence. Electrically stimulated skeletal muscle neosphincter is also appropriate for reconstruction after surgical excision of the anorectum in selected cases. Avoidance of complications requires strict attention to sterile technique, prophylactic antibiotics, and deep venous thrombus prophylaxis. A standardized scoring system is proposed that evaluates both continence and evacuation. Quality of life is a critical endpoint for assessing sphincter replacement, and use of The American Society of Colon and Rectal Surgeons incontinence-specific quality-of-life instrument is recommended. As the efficacy of sphincter replacement becomes proven, dissemination of the technique should occur in a controlled manner to ensure adequate surgeon training, minimization of complications, and optimization of results. CONCLUSIONS: Sphincter replacement by electrically stimulated skeletal muscle neosphincter and artificial anal sphincter provide a continent option for patients with end-stage fecal incontinence and those requiring abdominoperineal resection. The guidelines offered in this document are intended to facilitate the controlled and safe development and acceptance of these new techniques.

PURPOSE: This goal of this research was to develop and evaluate the psychometrics of a health-related quality of life scale developed to address issues related specifically to fecal incontinence, the Fecal Incontinence Quality of Life Scale. METHODS: The Fecal Incontinence Quality of Life Scale is composed of a total of 29 items; these items form four scales: Lifestyle (10 items), Coping/Behavior (9 items), Depression/Self-Perception (7 items), and Embarrassment (3 items). RESULTS: Psychometric evaluation of these scales demonstrates that they are both reliable and valid. Each of the scales demonstrate stability over time (test/retest reliability) and have acceptable internal reliability (Cronbach alpha >0.70). Validity was assessed using discriminate and convergent techniques. Each of the four scales of the Fecal Incontinence Quality of Life Scale was capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems. To evaluate convergent validity, the correlation of the scales in the Fecal Incontinence Quality of Life Scale with selected subscales in the SF-36 was analyzed. The scales in the Fecal Incontinence Quality of Life Scale demonstrated significant correlations with the subscales in the SF-36. CONCLUSIONS: The psychometric evaluation of the Fecal Incontinence Quality of Life Scale showed that this fecal incontinence-specific quality of life measure produces both reliable and valid measurement.

INTRODUCTION: This study sought to determine whether dietary arginine influences colonic anastomotic healing in the rat model. METHODS: Three groups of 42 Sprague-Dawley rats were fed 0, 1, and 3 percent arginine diets for three preoperative and three postoperative days. Animals underwent transection of the transverse colon with handsewn anastomosis. Subgroups of 14 animals in each dietary group were killed on postoperative Days 6, 10, or 14, and bursting pressures, histologic inflammation, and collagen content were compared. RESULTS: Mean anastomotic bursting pressures on postoperative Day 6 were lower for the 0 percent arginine group than the 1 and 3 percent arginine groups (mean ± standard error of the mean =134±6 mmHg, 164±7 mmHg, and 166±7 mmHg, respectively;P

PURPOSE: Hereditary nonpolyposis colorectal cancer is reported to have special histologic features. This study compares the histologic features of hereditary nonpolyposis colorectal cancer to colorectal cancers from the general population when hereditary nonpolyposis colorectal cancer cases are restricted to families with known MSH2 and MLH1 mutations. METHODS: Thirty-seven cancers from kindreds carrying MSH2 mutations, 27 cancers from kindreds carrying MLH1 mutations, and 37 colorectal cancers from the general population were reviewed by a pathologist blinded to hereditary nonpolyposis colorectal cancer gene status. Tumor grade, growth pattern, Crohn's-like lymphoid reaction, mucin production, extent of disease in the bowel wall, and lymph node status were evaluated. RESULTS: Poor differentiation and Crohn's-like reaction were a feature of 44 and 49 percent of hereditary nonpolyposis colorectal cancer compared with 14 percent (P=0.002) and 27 percent (P=0.049) of colorectal cancers from the general population, respectively. There was no difference in growth pattern, mucin production, lymph node involvement, or local extent of disease between hereditary nonpolyposis colorectal cancer and colorectal cancers from the general population. Poor differentiation and lymph node metastases were found in 57 and 49 percent of MSH2 compared with 26 percent (P=0.002) and 10 percent (P=0.03) of MLH1-associated cancers, respectively. There was no difference in growth pattern, mucin production, Crohn's-like lymphoid reaction, or local extent of disease between subgroups of hereditary nonpolyposis colorectal cancer. CONCLUSIONS: Poor differentiation and Crohn's-like reaction are more common in hereditary nonpolyposis colorectal cancer than colorectal cancers from general population. Poor differentiation and lymph node metastases are more commonly seen in MSH2-associated cancers than MLH1. Evaluation of the natural history, pathogenesis, and prognosis of colorectal cancer in hereditary nonpolyposis colorectal cancer should include consideration of which mismatch repair genes are mutated and what the specific mutations are.

INTRODUCTION: Transrectal ultrasound is the standard method for preoperative staging of rectal cancer. This study reviews the accuracy of transrectal ultrasound staging for T3 disease and its use in the selection of patients for neoadjuvant chemoradiation. METHODS: One hundred seventeen patients underwent preoperative transrectal ultrasound evaluation for rectal cancer. Accuracy of transrectal ultrasound was evaluated among 70 patients not receiving preoperative chemoradiation. Forty-seven patients received neoadjuvant chemoradiation based on transrectal ultrasound results. Tumor downstaging and early recurrence were evaluated among 45 of 47 patients receiving neoadjuvant chemoradiation. RESULTS: Among 70 nonirradiated patients, 19 were pathologic Stage pT3. Transrectal ultrasound correctly identified 18 of 19 patients with Stage pT3 (sensitivity, 94.7 percent). Transrectal ultrasound correctly identified 44 of 51 patients with less than pT3 disease (specificity, 86.3 percent). After preoperative chemoradiation in 45 patients with ultrasound Stage uT3 or uT4 tumors, 56 percent of them experienced a reduction in T stage. Residual nodal disease was found in 31 percent of patients. A complete pathologic response with no residual disease at operation was observed in 22 percent of patients. During a median follow-up period of 21 months after diagnosis, seven patients experienced a recurrence of their disease at a median of 12 months after diagnosis. Five of seven patients with recurrence were among a subgroup of ten patients who both failed to downstage T and had residual nodal disease at operation. CONCLUSION: Transrectal ultrasound is an accurate modality for selecting patients for neoadjuvant treatment. Preoperative chemoradiation produced downstaging in 56 percent of patients. Factors related to early recurrence included residual nodal disease and failure to downstage T after neoadjuvant chemoradiation.

One of the earliest references to heredity in colorectal cancer dates to Aldred Warthin's now-famous recollection of his seamstress' distress regarding “cancer excess” in her family history. her predication of an early demise secondary to cancer of the female organs, colon, or stomach proved true. The slow, arduous investigation that ensued followed a tortuous route of nearly eight decades before the implications of such family histories were widely acknowledged through the degisnation of hereditary nonpolyposis colorectal cancer or Lynch Syndrome Variants I and II. The story of hereditary nonpolyposis colorectal cancer is one of chance meetings, the selfless sharing of information, perseverance in the face of adversity, meticulous scientific documentation, and ultimate vindication by a scientific process that yielded molecular genetic evidence through the identification of the culprit mutations (hMSH2, hMLH1, hPMS2, and hMSH6). Our purpose is to provide a brief outline of the course charted by the study of the genetics of hereditary nonpolyposis colorectal cancer. This should be of particular interest to the readers of this Journal as we celebrate 100 years of dedication to the diagnosis and treatment of diseases of the colon, rectum, and anus through the efforts of The American Society of Colon and Rectal Surgeons.

PURPOSE: This clinical case review aimed to identify phenotypic variations in colorectal and extracolonic cancer expression between hereditary nonpolyposis colorectal cancer (HNPCC) families with MLH1 and MSH2 germline mutations and the general population. METHODS: Colorectal cancer onset and site distribution were compared among 67 members of MLH1 kindreds, 45 members of MSH2 kindreds, and 1,189 patients from the general population. Synchronous and metachronous cancer rates, tumor stage, extracolonic cancer incidence, and survival were also compared. RESULTS: Mean ages of colorectal cancer onset were 44, 46, and 69 years for MLH1, MSH2, and the general population, respectively (P

Knowing when to retire from a practice of medicine is perhaps one of the most vexing problems you as a physician will face during your career. For most physicians, your life has been devoted to caring for the sick, comforting the weary, relieving suffering, and promoting good health. Reaching that stage of your career where you see that there might be an end to your life’s work can be discouraging at best and overwhelmingly frightening at its worst. This chapter deals with some of the complexities of winding down a medical career, with an emphasis on surgery, providing some insight into thought processes and planning that can make the decision to retire manageable, and even exhilarating, when placed in the proper context.

Background : This prospective study assessed the effect of preoperative radiation and chemotherapy on the pathologic staging of advanced rectal cancer. Methods : Twenty patients with rectal cancer were treated with combined chemoradiation prior to operation, after pretreatment staging of all lesions with transrectal ultrasound (TRUS). Perirectal fat invasion served as minimal criteria for preoperative neoadjuvant therapy. The pretreatment stage of these rectal lesions as defined by TRUS was then compared with the pathological stage of the surgical specimen following resection. Cancers were treated with high-dose radiation (45 to 54 Gy) in 19 of 20 patients. One patient received in excess of 60 Gy because of tumor characteristics. Chemotherapy consisted of 5-fluorouracil delivered as a continuous infusion or bolus therapy. Four to 8 weeks after neoadjuvant therapy, 13 abdominal perineal resections, 5 low anterior resections, and 2 completion proctectomies were performed. Results : Following resection, rectal cancer was downstaged in 14 of 20 patients. No tumor was present in the rectal wall in 8 of 20 patients. Complete pathological response was present in 7 of 20 patients. Local recurrence occurred in 2 of 20 patients. Disease-free survival in the remaining 17 of 20 patients ranges from 9 to 51 months (average 26). Conclusions : Preoperative chemoradiation in the surgical management of advanced rectal cancer results in demonstrable tumor downstaging.

PURPOSE: We sought to evaluate a new diagnostic technique for the identification of rectal and pelvic floor pathology in patients with obstructed defecation, pelvic fullness/ prolapse, and/or chronic intermittent pelvic floor pain. METHODS: Thirteen symptomatic women with either a nondiagnostic physical examination or nondiagnostic dynamic proctography (DPG) were studied. After placement of intraperitoneal and intrarectal contrast material, resting and straining pelvic x-rays were obtained in all patients, and defecation was videotaped using fluoroscopy. RESULTS: Simultaneous DPG and peritoneography identified clinically suspected and unsuspected enteroceles in 10 of the 13 patients studied. An enterocele or other pelvic floor hernia was ruled out by the technique in three of the women studied. Rectoceles and rectal prolapse that were identified during physical examination were confirmed by DPG with peritoneography. Simultaneous DPG and peritoneography also gave a qualitative assessment of the severity and clinical significance of the identified pelvic floor disorders. Results of simultaneous DPG and peritoneography affected operative treatment planning in 85 percent of patients studied. CONCLUSION: Simultaneous DPG and peritoneography identifies both rectal and pelvic floor pathology and provides a qualitative assessment of pelvic floor pathology severity, which allows for better treatment planning in selected patients with obstructed defecation and pelvic prolapse.

PURPOSE: This study sought to identify clinical and manometric characteristics of male fecal incontinence. METHOD: Clinical charts of 25 men with a chief complaint of fecal incontinence were retrospectively reviewed. Their anorectal physiology test results were compared with those from a group of 20 healthy men. RESULTS: Fourteen men (56 percent) were “leakers,” who complained of loss of liquid or solid stool smears that stained their underclothes. Eleven men (44 percent) had true incontinence, with loss of control over gas, liquid, and/or solid stool. Leakers had lower anal sphincter pressures than normal men (P

PURPOSE: This preliminary study was undertaken to clarify the role of ultrasonography of anal sphincters in the colorectal laboratory. METHODS: Twenty-eight parous female patients with fecal incontinence were evaluated with transanal ultrasonography (TAUS), anal manometry, and pudendal nerve terminal motor latency (PNTML). Ultrasound images were recorded and labeled in centimeters from the anal verge. The continuity of the internal anal sphincter (IAS) was identified as either intact or disrupted. The separation of the external anal sphincter (EAS) was measured at the 1.5-cm level and below. TAUS findings were then compared with anal manometric pressures. Clinical data were obtained by patient interview and examination during TAUS. RESULTS: Evidence of IAS disruption was associated with significantly decreased mean maximum resting pressures (P=0.023). EAS separation was inversely proportional to mean maximum squeezing pressures (r=−0.61). In the group of patients offered sphincteroplasty, the IAS was disrupted more often (P=0.016), mean maximum resting pressures were significantly lower (P=0.023), mean EAS separation was significantly greater (P=0.022), and mean PNTML was significantly faster (P=0.004). Twenty-five percent of patients with normal clinical examinations had significant muscular injury by TAUS requiring sphincteroplasty. CONCLUSIONS: Manometric findings correlate significantly with anal sphincter defects visualized by TAUS. TAUS is useful in the evaluation and management of patients with fecal incontinence.

PURPOSE: Positron emission tomography (PET) is an imaging technique based onin vivo cellular metabolism. Increased glucose metabolism in neoplastic cells is detected by using fluorine-18 deoxyglucose. In an ongoing pilot study to determine the usefulness of this technique, PET is compared with computerized tomography (CT) for the preoperative staging of colorectal carcinoma. METHODS: Sixteen patients were evaluated with both PET and CT of the abdomen and pelvis. Results were compared with operative and histopathologic findings. Fifteen malignant lesions were found in 16 patients by histology. PET had a positive predictive value of 93 percent and a negative predictive value of 50 percent. By comparison CT had a positive predictive value of 100 percent and a negative predictive value of 27 percent. CONCLUSIONS: These preliminary results indicate that PET has increased sensitivity for staging colorectal carcinoma, whereas CT has higher specificity. The predictive value of a positive PET compares favorably with CT. Furthermore, the predictive accuracy for detection of colorectal carcinoma is 83 percent for PET and 56 percent for CT.

Guidelines for cancer screening written by different organizations often differ, even when they are based on the same evidence. Those dissimilarities can create confusion among health care professionals, the general public, and policy makers. The Institute of Medicine (IOM) recently released 2 reports to establish new standards for developing more trustworthy clinical practice guidelines and conducting systematic evidence reviews that serve as their basis. Because the American Cancer Society (ACS) is an important source of guidance about cancer screening for both health care practitioners and the general public, it has revised its methods to create a more transparent, consistent, and rigorous process for developing and communicating guidelines. The new ACS methods align with the IOM principles for trustworthy clinical guideline development by creating a single generalist group for writing the guidelines, commissioning independent systematic evidence reviews, and clearly articulating the benefits, limitations, and harms associated with a screening test. This new process should ensure that ACS cancer screening guidelines will continue to be a trustworthy source of information for both health care practitioners and the general public to guide clinical practice, personal choice, and public policy about cancer screening.

PURPOSE: The effect of prostaglandin E1 (PGE1) and corticosteroids alone and in combination were studied in the healing rat colon to determine whether PGE1 could not only improve healing but reverse the negative effect of steroids on colonic wound healing. METHODS: Colonic anastomoses were performed in 144 male Sprague-Dawley rats divided into four groups. The control group (I) received no further treatment. The steroid group (II) received cortisone acetate (5 mg/kg/day) beginning six days preoperatively and continuing until sacrifice. The PGE1 group (III) received 2 μg of PGE1 intra-aortically at surgery and for three days postoperatively. The combination PGE1/steroid group (IV) received both drugs in the same doses as those in Groups II and III. Animals were sacrificed on postoperative days 6, 10, and 14. Wound healing was evaluated by hydroxyproline content, bursting pressures, and histology. RESULTS: The hydroxyproline assay at day 10 revealed that steroid-treated rats have significantly lower levels than any other group. The PGE1 group (III) had the highest level of significance in comparison to the steroid group (II) (P=0.001). The addition of PGE1 to steroid (Group IV) appeared to abolish the negative effect of the steroid as measured by hydroxyproline content on day 10 (P=0.038). When measuring bursting pressures, the PGE1 group (III) had significantly higher pressures than any other group at day 10. However, no amelioration of the steroid effect on bursting pressures was seen. Histologic evaluation of the anastomosis did not reveal any significant differences among the four groups. CONCLUSIONS: PGE1 reverses the negative effect of the steroid on hydroxyproline levels at day 10. Furthermore, using bursting pressure as a parameter of wound healing, administration of PGE1 results in significantly improved anastomotic healing at day 10.

A multicenter retrospective study was undertaken to assess the efficacy and safety of laparoscopy in colon and rectal surgery. To minimize potential bias in interpretation of the results, all data were registered with an independent observer, who did not participate in any of the surgical procedures. Sixty-six patients underwent a laparoscopic procedure. Operations performed included sigmoid colectomy (19), right hemicolectomy (15), low anterior resection (6), colectomy with ileal pouch-anal anastomosis (IPAA) (5), and abdominoperineal resection (APR) (3). The conversion rate from laparoscopic colectomy to celiotomy was 41 percent. Major morbidity and mortality were 24 percent and 0 percent, respectively. Length of stay, hospital costs, and lymph node harvest were compared between the sigmoid resection and right hemicolectomy subgroups. Data from traditional sigmoid colectomies and right hemicolectomies were obtained from the same institutions for comparison. Mean postoperative stay for laparoscopically completed sigmoid and right colectomies was significantly less than that for either the converted or the traditional groups (P

To test the hypotheses that older patients with colorectal cancer (CRC) and rural patients are less likely to undergo surgery, radiation, and chemotherapy.Retrospective study.A total of 6561 patients with CRC between January 1998 and December 2003 were identified by incident International Classification of Diseases for Oncology codes from the Nebraska Cancer Registry. In multivariate logistic regression analyses, we studied the association of age and residence county (rural vs urban and micropolitan) with each of 3 CRC treatments by anatomic site.After adjusting for patient demographics, insurance payer, ratio of providers to population, and cancer stage, patients with colon cancer living in micropolitan counties were more likely to receive chemotherapy than those living in rural counties (P.001). Compared with patients aged 19 to 64 years, patients with colon cancer 85 years and older (P.001) and patients with rectal cancer 75 years and older (P.05) were less likely to undergo surgery. Patients with CRC 75 years and older were less likely to receive radiation, and patients with colon cancer 65 years and older and patients with rectal cancer 75 years and older were less likely to receive chemotherapy (P.001 for both).In Nebraska, older patients with CRC were less likely to undergo surgery, radiation, and chemotherapy. Patients with colon cancer in rural counties were less likely to undergo chemotherapy than those in micropolitan counties. Decision makers need to consider issues of age and rural residence in patient access to CRC treatments.

Treatment modalities in rectal cancer have undergone a slow, evolutionary transition over the past 30 years. More recently, contemporary descriptions of advanced preoperative chemotherapy and radiation schema have led to a rapid revolution in the management of this disease. In this review we focus on current evidence-based neoadjuvant strategies used in the treatment of locally advanced rectal cancer and metastatic rectal disease. Finally, we provide a foundation for discussion of still unresolved issues.