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Background and objectives To investigate the feasibility of delivering a functional exercise-based prehabilitation intervention and its effects on postoperative length of hospital stay, preoperative physical functioning and health-related quality of life in elective colorectal surgery. Materials and methods In this randomised controlled feasibility trial, 22 elective colorectal surgery patients were randomly assigned to exercise prehabilitation (n = 11) or standard care (n = 11). Feasibility of delivering the intervention was assessed based on recruitment and compliance to the intervention. Impact on postoperative length of hospital stay and complications, preoperative physical functioning (timed up and go test, five times sit to stand, stair climb test, handgrip dynamometry and 6-min walk test) and health-related quality of life were also assessed. Results Over 42% of patients (84/198) screened were deemed ineligible for prehabilitation due to insufficient time existing prior to scheduled surgery. Of those who were eligible, approximately 18% consented to the trial. Median length of hospital stay was 8 [range 6–27] and 10 [range 5–12] days respectively for the standard care and prehabilitation groups. Patterns towards preoperative improvements for the timed up and go test, stair climb test and 6-min walk test were observed for all participants receiving prehabilitation but not standard care. Conclusions Despite prehabilitation appearing to convey positive benefits on physical functioning, short surgical wait times and patient engagement represent major obstacles to implementing exercise prehabilitation programmes in colorectal cancer patients.

Ileal pouch-anal anastomosis (IPAA) has been established as the procedure of choice for patients who require excision of the colon and rectum for familial adenomatous polyposis and ulcerative colitis. The requirement for proximal stomal diversion in IPAA is controversial. To compare post-operative outcomes following IPAA with and without proximal diversion. Computerised literature search, of Ovid MEDLINE and EMBASE. Full-text comparative studies published between 1992 and 2019, in English language and on adult patients. Ileal pouch-anal anastomosis with or without proximal stomal diversion following proctocolectomy. Outcome measures were anastomotic leak, anastomosis strictures, re-operations, pouch failure, intra-abdominal sepsis, small bowel obstruction/ileus and mortality. Five hundred and forty-six studies were screened. Fourteen relevant studies included 4973 cases (1832 patients with no stomas vs 3141 with stomas). Anastomotic strictures (p ≤ 0.0001 OR 0.40; 95% CI (0.26–0.62)) and pouch failures (p = 0.003 OR 0.54; 95% CI (0.36–0.82)) were higher in diverted than non-diverted patients. Re-operation was more frequently required in non-diverted patients (p = 0.02 OR 2.51; 95% CI (1.12–5.59)). Heterogeneity was low in 5 out of 7 variables. In selected patients, diversion-free IPAA is a safe procedure associated with lower anastomotic stricture and pouch failure rates than diverted IPAA. This appears to occur at the expense of a higher re-operation rate. An RCT is required to help define the selection criteria.

Aim The medical management of inflammatory bowel disease (IBD) in pregnancy and the puerperum is well defined. Data on surgical management of complicated IBD in this setting are lacking. The study aimed to determine the optimal surgical strategy for medically refractory IBD during pregnancy and the puerperium. Method Three databases were systematically reviewed to identify all published series or case reports of females undergoing surgery for Crohn's disease (CD) or ulcerative colitis (UC) while pregnant or in the puerperium. Results Thirty two papers were identified including 86 patients. Nearly one fifth (18%) of cases were de novo presentations and intervention was required at all stages of pregnancy. UC refractory to medical treatment and perforated small bowel CD were the commonest indications for surgery. Operations used included colectomy, colectomy with mucous fistula and Turnbull-blowhole colostomy for complicated UC and open or laparoscopic small bowel resection with stoma formation for CD. Surgical intervention during the third trimester universally resulted in the onset of labour. Endoscopic and radiological interventions were rarely employed. In contemporary studies (after 1980) there was no maternal or foetal mortality but there was an almost 50% pre-term delivery rate. Conclusion Surgical management of complicated IBD during pregnancy and the puerperium needs to be tailored to disease severity, the type of complications and foetal status. It should involve gastroenterologists, colorectal surgeons, obstetricians and neonatal specialists in a multidisciplinary manner within a single unit. This article is protected by copyright. All rights reserved.

Background There are no data comparing the quality of local excision of rectal neoplasms using transanal endoscopic microsurgery and transanal minimally invasive surgery. Objective The purpose of this study was to compare the incidence of tumor fragmentation and positive margins for patients undergoing local excision of benign and malignant rectal neoplasms using transanal endoscopic microsurgery versus transanal minimally invasive surgery. Design This was a multi-institutional cohort study using coarsened exact matching. Settings The study was conducted at high-volume tertiary institutions with specialist colorectal surgeons. Patients Patients undergoing full-thickness local excision for benign and malignant rectal neoplasms were included. Interventions Transanal endoscopic microsurgery and transanal minimally invasive surgery were the included interventions. Main outcome measures The incidence of poor quality excision (composite measure including tumor fragmentation and/or positive resection margin) was measured. Results The matched cohort consisted of 428 patients (247 with transanal endoscopic microsurgery and 181 with transanal minimally invasive surgery). Transanal minimally invasive surgery was associated with shorter operative time and length of stay. Poor quality excision was similar (8% vs 11%; p = 0.233). There were also no differences in peritoneal violation (3% vs 3%; p = 0.965) and postoperative complications (11% vs 9%; p = 0.477). Cumulative 5-year disease-free survival for patients undergoing transanal endoscopic microsurgery was 80% compared with 78% for patients undergoing transanal minimally invasive surgery (log rank p = 0.824). The incidence of local recurrence for patients with malignancy who did not undergo immediate salvage surgery was 7% (8/117) for transanal endoscopic microsurgery and 7% (7/94) for transanal minimally invasive surgery (p = 0.864). Limitations All of the procedures were also performed at high-volume referral centers by specialist colorectal surgeons with slightly differing perioperative practices and different time periods. Conclusions High-quality local excision for benign and rectal neoplasms can be equally achieved using transanal endoscopic microsurgery or transanal minimally invasive surgery. The choice of operating platform for local excisions of rectal neoplasms should be based on surgeon preference, availability, and cost. See Video Abstract at http://links.lww.com/DCR/A382.

Several reports have described a relationship between tumor volume and oncological outcomes for certain cancers. There is paucity of similar data for rectal cancer. We conducted this study to establish whether tumor volume, mesorectal volume, and the tumor volume to mesorectal volume ratio (TV/MRV), evaluated by magnetic resonance imaging (MRI), affect the oncological outcomes of patients with rectal cancer. We performed volumetric analysis of rectal tumors from magnetic resonance imaging (MRI) images and assessed their correlation with oncological outcomes, using clinical and radiological databases. The subjects of this study were 25 of 35 patients who underwent rectal cancer surgery after staging with MRI, after the exclusion of 7 patients for whom MRI images could not be retrieved and 3 patients who had metastases identified at diagnosis. Tumor volume (TV) was a significant predictor of overall survival hazard ratio (95 % CI); 5.8 (1.2–29), (P = 0.03). Mesorectal volume (MRV) and TV/MRV did not correlate with oncological outcomes. We found a direct relationship between tumor volume and overall survival, which may be used to stratify rectal tumors for neoadjuvant therapy. A larger prospective study is required to confirm this correlation.

Aim Chronic pelvic sepsis is a challenging problem, which may require muscle flaps to fill the pelvic cavity. The aim of this systematic review was to determine the relative success of rectus and gracilis flaps used for this purpose. Method A systematic review was conducted to identify papers that reported the outcome of rectus or gracilis myocutaneous flaps in the treatment of persistent perineal sinuses or chronic pelvic sepsis. Reports of muscle flaps used for reconstruction or treatment of fistula in the absence of chronic sepsis were excluded. A successful outcome was defined as complete perineal healing within 12 months of surgery. Results The review identified 19 studies reporting the outcome of 73 rectus and 87 gracilis flaps. Their respective success was 84% and 64%. Heterogeneity of the underlying cases did not allow for direct comparison of the flaps. Full healing of the flaps was generally achieved within 3 months. Donor site morbidity was minimal. Conclusion The surgical treatment of chronic pelvic sepsis should be tailored to the individual, but the rectus flap has a reasonable success rate with little morbidity.

Aim This study set out to compare the postoperative health related quality of life (HQoL) of patients undergoing elective open colorectal surgery using a well-established enhanced recovery after surgery (ERAS) pathway with those undergoing laparoscopic surgery without an established an ERAS pathway. Method Using a power calculation, it was estimated that 40 patients would be required in each group. HQoL of the two groups was prospectively assessed using SF-12 (Short Form 12) and EORTC QLQ 30 (European Organisation of Research and Treatment of Cancer, Quality of Life Questionnaire) preoperatively, and at 2 and 6 weeks after discharge. Results Data were collected from 83 patients, 41 in the laparoscopic group and 42 in the open–ERAS group. There was a significant difference between the median length of stay of the open–ERAS (5 days) and laparoscopic (7 days, P = 0.028) groups. There were no significant differences between the HQoL score of the two groups at any stage. In both groups, the majority of HQoL scores had improved considerably by 6 weeks. Conclusion Laparoscopic and open–ERAS surgery have a similar impact on postoperative HQoL. HQoL tends to improve by the 6-week stage.

OBJECTIVES The potential to predict, and therefore avoid, anastomotic failure has eluded generations of colon and rectal surgeons to date. A reliable, reproducible method of assessing bowel blood flow therefore would be of enormous potential clinical relevance. To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We present our study assessing the feasibility of using contrast-enhanced sonography to study bowel perfusion intraoperatively. METHODS We studied 8 patients (4 male and 4 female) with an age range of 52 to 81 years who underwent colorectal surgery (right hemicolectomies, n = 3; Hartmann procedure, n = 1; anterior resections, n = 2; and bowel resections with ileocolic anastomoses, n = 2). A 5-mL bolus of a sulfur hexafluoride contrast agent solution was injected before and after vascular ligation with simultaneous noncompression ultrasound scanning directly over the large bowel. The patients were followed clinically to assess for leaks. Contrast-enhanced sonographic time-intensity curves were generated for the time to peak and maximum amplitude. RESULTS Moderate interobserver agreement was shown for the time to peak (κ = 0.50) and maximum amplitude (κ = 0.42), and moderate intraobserver agreement was shown for the time to peak (κ= 0.53) and maximum amplitude (κ= 0.53). No significant differences were shown between the time to peak (P = .28) and maximum amplitude (P = .49) for the preligation and postligation scans. CONCLUSIONS To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We have shown the technique to be feasible with good intraobserver and interobserver agreement. Further work is ongoing to optimize the technique and assess its use in predicting anastomotic breakdown.

Background. In this modern era of multi-modality treatment there is increasing interest in the possibility of avoiding radical surgery in complete responders after neo-adjuvant long-course chemoradiotherapy (LCPRT). In this article, we present a systematic review of such treatments and discuss their therapeutic applicability for the future. Methods. We searched the PubMed online libraries to identify studies that reported on the long-term surgical and pathological outcomes after local excision together with those that explored the possibility of clinical observation only in patients achieving a complete clinical response after LCPRT. Results. Several retrospective (n 10), one single-arm prospective, and one small randomised series have reported on the use of local excision after LCPRT and demonstrated acceptably low levels of local recurrence with survival comparable to patients progressing to conventional surgery. One prospective series allocated patients to observation or radical surgery based on histological parameters after local excision (ypT0 and ypT1) and showed no differences in outcomes. Two retrospective series from the same group on a Brazilian cohort of patients reported excellent long-term outcomes after “ wait and watch ” in complete clinical responders. However, other reports have shown no direct correlation between clinical and pathological response. Conclusion. Local excision may be an appropriate option for selected patients developing good clinical response after LCPRT. In our opinion, a policy of clinical observation in complete clinical responders after LCPRT may not be a safe strategy, unless we had robust predictive models for accurate identifi cation of pathological complete response. In order to identify patients that may be potentially appropriate for such an approach we propose a clinical algorithm incorporating important clinical, radiological, and pathological parameters. The proposed model will require validation in a prospective study. Finally, we need randomised data for demonstrating the non-inferiority of clinical observation compared to conventional surgery before this can be considered as standard possible therapeutic option.

The diagnosis of invasive malignancy on biopsies from colorectal neoplasms can be challenging. The concept of intramucosal carcinoma as an indicator of invasive malignancy is somewhat controversial within histopathology circles despite current World Health Organization (WHO) definitions. This study was designed to correlate the biopsy finding of intramucosal carcinoma with the pathology findings after formal surgical excision. We evaluated 89 patients whose initial forceps biopsy contained only intramucosal carcinoma. All tumors were subsequently resected and subjected to formal pathology assessment. Of 89 patients, 97% were shown to have frankly invasive adenocarcinoma by the current WHO definition. The positive predictive value of intramucosal carcinoma at biopsy for invasive cancer was 96.6% This study indicated that there should be a greater willingness among colorectal pathologists to accept the biopsy finding of intramucosal carcinoma as the earlier form of invasive malignancy. Clinicians should alter their treatment algorithms accordingly.

Objective Virtual colonoscopy (VC)/CT colonography has advantages over the well-documented limitations of colonoscopy/barium enema. This prospective blinded investigative comparison trial aimed to evaluate the ability of VC to assess the large bowel, compared to conventional colonoscopy (CC), in patients at high risk of colorectal cancer (CRC). Method We studied 150 patients (73 males, mean age 60.9 years) at high risk of CRC. Following bowel preparation, VC was undertaken using colonic insufflation and 2D-spiral CT acquisition. Two radiologists reported the images and a consensual agreement reached. Direct comparison was made with CC (performed later the same day). Interobserver agreement was calculated using the Kappa method. Postal questionnaires sought patient preference. Results Virtual colonoscopy visualized the caecum in all cases. Five (3.33%) VCs were classified as inadequate owing to poor distension/faecal residue. CC completion rate was 86%. Ultimately, 44 patients had normal findings, 44 had diverticular disease, 11 had inflammatory bowel disease, 18 had cancers, and 33 patients had 42 polyps. VC identified 19 cancers – a sensitivity and specificity of 100% and 99.2% respectively. For detecting polyps > 10 mm, VC had a sensitivity and specificity (per patient) of 91% and 99.2% respectively. VC identified four polyps proximal to stenosing carcinomas and extracolonic malignancies in nine patients (6%). No procedural complications occurred with either investigation. A Kappa score achieved for interobserver agreement was 0.777. Conclusion Virtual colonoscopy is an effective and safe method for evaluating the bowel and was the investigation of choice amongst patients surveyed. VC provided information additional to CC on both proximal and extracolonic pathology. VC may become the diagnostic procedure of choice for symptomatic patients at high risk of CRC, with CC being reserved for therapeutic intervention, or where a tissue diagnosis is required.

Aims: Radiotherapy (RT) reduces local recurrence in rectal cancer but the optimal treatment schedule is unknown. Relevant questions in designing optimal therapy are set out. This review identifies evidence that influences current practice and shapes future trials in treatment of operable rectal cancer. Methods: PubMed and MEDLINE search. Results: RT reduces local recurrence and pre-operative treatment is superior to post-operative treatment. Longer interval to surgery and concurrent chemotherapy are associated with greater downstaging, although influence on sphincter preservation and survival is minimal. Short-course RT (SCRT) demonstrates lower recurrence, but with long-term dysfunction and minimal survival benefit. The role of SCRT should be re-evaluated to encompass new criteria/areas. Conclusion: SCRT should be used selectively rather than as a blanket treatment policy. SCRT compounds functional morbidity caused by mesorectal excision which may be excessive in some patient groups, especially early-stage rectal cancer or frail elderly patients. RT and local excision may be a feasible surgical alternative in these groups. Alternatively, SCRT and delayed surgery may be a future alternative to current long-course chemoradiotherapy. As survival is only marginally affected despite low local recurrence, future trials should aim to address metastatic disease. End points which incorporate function and quality of life must be used.

Lower gastrointestinal hemorrhage is a common reason for hospital admission. Spontaneous cessation occurs in the majority of these patients; however, continued major bleeding is a difficult clinical problem. Emergency surgery, without prior knowledge of the bleeding site is associated with high morbidity and mortality rates. Accurate localization is therefore desirable. The authors present a review of current radiological imaging modalities and therapeutic options available to the clinician. They also provide a management algorithm to aid in the strategic management of this group of patients.

Background/Aims: Anastomotic failure occurs in up to 10% of patients following anterior resection. Selective use of a loop ileostomy may reduce the septic consequences of anastomotic leak. The use of gastrograffin enema to confirm the anastomotic integrity prior to ileostomy closure is still controversial. Our aim was to determine the impact of the routine use of gastrograffin enema on patients’ management prior to ileostomy reversal. Methods: A review of 81 patients who underwent low anterior resection with loop ileostomy for rectal cancer over 3 years. Results: Gastrograffin enema was performed in 69 patients (85.2%). The mean time from operation to gastrograffin enema was 22 weeks. Four patients (5.8%) had a positive radiological leak without clinical suspicion of anastomotic problems, 2 patients (2.9%) of these subsequently had the ileostomy closed despite the positive result, 2 patients (2.9%) had a gastrograffin enema repeated which showed no leak and the patients are awaiting reversal. Conclusion: The incidence of positive radiological leak in uncomplicated patients is low; such patients had their loop ileostomies closed with or without serial gastrograffin enema. Routine gastrograffin enema in the absence of a clinical suspicion of anastomotic failure would appear to be of little value.

This study was designed to determine whether routine follow-up by magnetic resonance imaging improves the detection of resectable liver metastases from colorectal cancer and patients' survival. Patients who underwent curative surgery for colorectal cancer were included in a program of liver surveillance by routine magnetic resonance imaging, in addition to the standard follow-up protocol consisting of clinical examination and biochemical tests. The median follow-up was 41 (interquartile range, 30–53) months, with a median magnetic resonance imaging surveillance period of 20 (interquartile range, 12–27) months. Cases were analyzed for mode of diagnosis, resectability, and overall survival. Liver metastases were found in 37 (13 percent) of 293 patients studied. Magnetic resonance imaging diagnosed hepatic metastases with 84 percent sensitivity and 90 percent specificity. In 28 (76 percent) patients, carcinoembryonic antigen and/or liver function tests were abnormally elevated and 5 patients (14 percent) were symptomatic. Hepatic resection was possible in only nine patients (24 percent). Magnetic resonance imaging detected all resectable cases, whereas traditional follow-up would have missed three (33 percent) cases suitable for surgery. Although magnetic resonance imaging surveillance increased the number of patients suitable for liver resection by 50 percent, these represented only 1 percent of the patients included in the study. Whether these results are enough to justify the allocation of expensive resources is controversial.

A major source of morbidity after abdominoperineal resection (APR) after external beam pelvic radiation is perineal wound complications, seen in up to 66% of cases. Our purpose was to determine the effect of rectus abdominus myocutaneous (RAM) flap reconstruction on perineal wound morbidity in this population.The study group consisted of 19 patients with anorectal cancer treated with external beam pelvic radiation followed by APR and RAM flap reconstruction of the perineum. A prospectively collected database was queried to identify a control group (n = 59) with anorectal cancer treated with similar radiation doses that subsequently underwent an APR without a RAM flap during the same time period. Comparison of percentages was performed with a two-sided Fisher's exact test, and comparison of means was performed with Wilcoxon's test.Perineal wound complications occurred in 3 (15.8%) of the RAM flap patients and 26 (44.1%) of the control patients (P = .03). The incidence of other complications was not different between groups (42.1% vs. 42.4%; P = .8). Despite an increased number of anal squamous tumors, an increased vaginectomy rate, increased use of intraoperative radiotherapy, and an increased proportion of cases with recurrent disease, the flap group had a significantly lower rate of perineal wound complications relative to the control group.Perineal closure with a RAM flap significantly decreases the incidence of perineal wound complications in patients undergoing external beam pelvic radiation and APR for anorectal neoplasia. Because other complications are not increased, RAM flap closure of the perineal wound should be strongly considered in this patient population.

Background: Appendiceal carcinoma (AC) is a rare entity that does not have a well-defined treatment strategy. At presentation, most patients are clinically thought to have appendicitis and the diagnosis is made only by formal histology. Once the diagnosis of AC is made, patients are treated by various strategies including surgery, chemotherapy depending on nodal status of the disease. Aim: To review the Hull hospitals’ experience with AC. Methods: Between 1982 and 2002, 10 patients with primary AC were seen. The histopathology reports of all appendiceal specimens removed were traced. Follow-up was by chart review or patient follow-up as appropriate. We did not include patients with primary carcinoid tumours or secondary adenocarcinoma. Results: There was an equal sex distribution. All patients underwent surgery, 3 had post-operative chemotherapy. Complete follow-up information was available with a median follow-up time of 56 months, with a range of 12–168 months. Five patients survived at least 4 years from the time of diagnosis. Conclusion: Long-term survival in patients with AC is possible.

Ileal pouch-anal anastomosis has come to represent the procedure of choice for patients requiring surgery for mucosal ulcerative colitis. In contrast, a proven diagnosis of Crohn’s disease is generally held to preclude ileal pouch-anal anastomosis. However, patients with ileal pouch-anal anastomosis for apparent mucosal ulcerative colitis who are subsequently found to have Crohn’s disease have a variable course. We reviewed our experience in this scenario to determine whether selected patients with Crohn’s disease may be candidates for ileal pouch-anal anastomosis. A retrospective review of the prospectively maintained ileal pouch-anal anastomosis database was undertaken to identify patients with a diagnosis of Crohn’s disease after ileal pouch-anal anastomosis. Clinical outcome and quality-of-life data were obtained from the database and chart review. End points were the development of recrudescent Crohn’s disease, pouch failure, and quality of life and functional outcome at the time of data collection. Differences between groups were calculated using the chi-squared test. Cumulative incidence of recrudescent Crohn’s disease and pouch loss were calculated by the Kaplan-Meier method. Factors predictive of development of recrudescent Crohn’s disease and pouch loss were examined by univariate analysis. Sixty patients (32 females; median age, 33 (range, 15–74) years) who underwent ileal pouch-anal anastomosis for mucosal ulcerative colitis subsequently had that diagnosis revised to Crohn’s disease. Median follow-up of all patients was 46 (range, 4–158) months at time of data collection by which time 21 patients (35 percent) had developed recrudescent Crohn’s disease. No pre-ileal pouch-anal anastomosis factors examined were predictors of the development of recrudescent Crohn’s disease on univariate analysis. Median follow-up of the latter group was 63 (range, 0–132) months from time of diagnosis, by which time six patients underwent pouch excision and another patient was permanently defunctioned. The overall pouch loss rate for the entire cohort was 12 percent and 33 percent for those with recrudescent Crohn’s disease. Median daily bowel movements in those with ileal pouch-anal anastomosis in situ at the time of data collection was 7 (range, 3–20), with 50 percent of patients rarely or never experiencing urgency and 59 percent reporting perfect or near perfect continence. Median quality of life, health, and happiness scores were 9.9 and 10 of 10. The secondary diagnosis of Crohn’s disease after ileal pouch-anal anastomosis is associated with protracted freedom from clinically evident Crohn’s disease, low pouch loss rate, and good functional outcome. Such results only can be improved by the continued development of medical strategies for the long-term suppression of Crohn’s disease. These data support a prospective evaluation of ileal pouch-anal anastomosis in selected patients with Crohn’s disease.

The behavior of intra-abdominal desmoids in familial adenomatous polyposis is incompletely understood. Findings range from typical mass lesions to flat sheets, termed the desmoid reaction or desmoid precursor lesion. The latter often are incidental findings of uncertain significance. The study was designed to describe the natural history of incidental intra-abdominal desmoid tumors with particular reference to the desmoid reaction. Patients who underwent laparotomy for familial adenomatous polyposis at the Cleveland Clinic Foundation were identified. The incidence of incidental intra-abdominal desmoid tumors was determined by review of operative records. Intra-abdominal desmoid tumors were classified as mass lesions if three-dimensional or desmoid reaction if two-dimensional. The incidence of clinically apparent intra-abdominal desmoid tumors (typical mass lesions on physical examination or cross-sectional imaging in symptomatic patients) was determined by chart review. The incidence of clinical intra-abdominal desmoid tumors between groups was compared by Fisher’s exact test. A total of 266 patients (153 females; median age, 26 (range, 9–63) years) underwent abdominal surgery for familial adenomatous polyposis. Incidental intra-abdominal desmoid tumors were identified in 34 patients: 8 at the index surgery and 26 at relaparotomy. These lesions influenced the planned procedure in eight cases (26 percent), including preventing ileoanal pouch in 3 of 19 patients in whom this was intended. The median follow-up from the time of identification of intra-abdominal desmoids was 42 (range, 2–178) months at which point four patients (11 percent) had developed clinical intra-abdominal desmoid tumors. There was no significant difference in incidence of clinical intra-abdominal desmoid tumors between mass and desmoid reaction groups (P = 0.27). Incidental intra-abdominal desmoid tumors are a common finding at relaparotomy in patients with familial adenomatous polyposis. These lesions influence planned surgery in a minority of cases. Desmoid reaction may have little bearing on the subsequent development of clinically significant intra-abdominal desmoid tumors.

Background and Aim: Most patients with hepatic metastases from colorectal carcinoma are unsuitable for resection. Radiofrequency ablation (RFA) has been applied to such lesions at laparotomy. This study aimed to evaluate the less invasive approach of percutaneous RFA. Method: Patients with unresectable liver metastases identified on cross-sectional imaging were considered for percutaneous RFA either alone or in combination with systemic chemotherapy. Subjects with >6 lesions or lesions of maximum size >70 mm were excluded. Percutaneous RFA was applied under sedation and radiological guidance (CT/US). Treatment effect was determined by follow-up imaging. Actuarial survival was calculated by the Kaplan-Meier analysis. Results: Thirty patients (21 males), median age 74.5 years (range 44–85 years), underwent percutaneous RFA to 56 lesions during 54 treatment sessions. The median size of lesion was 30 mm (range 8–70 mm). Fifteen lesions were treated more than once because of recurrence or incomplete ablation. The median ablation time per lesion was 12 min (range 4.5–36 min). Eleven patients had pre-procedural chemotherapy and 15 patients received chemotherapy after treatment. There was minimal associated morbidity (5.6% of treatments). Median hospital stay per treatment was 1 day (range 1–7). Median actuarial survival from the date of first percutaneous RFA was 22 months (95% CI 12.9–31.1 months). Eleven patients were alive at the time of data collection. Conclusion: Percutaneous RFA is a safe, well-tolerated intervention for unresectable hepatic metastases which can be repeated, if required. The technique may be associated with prolonged survival in this selected group of subjects. Future studies should consider the role of percutaneous RFA either in place of or as an adjunct to palliative chemotherapy.

Background: We aimed to determine the outcome of resections for local recurrence of colorectal carcinoma in the presence of distant (M1) disease. Methods: Patients who underwent resection of local recurrence in the presence of potentially resectable M1 disease were identified from the colorectal database. Outcome was determined by chart review. Results: Forty-two patients (23 men) of mean age 60 years (range, 34–88 years) underwent complete gross resection of their local recurrence in the presence of M1 disease. Thirteen of the 42 underwent synchronous M1 resections to render them free of gross disease (R0). Nine of the 29 patients who left with residual disease (R1) subsequently underwent staged M1 resection, so that 22 of 42 were rendered R0 by surgery. The median survival of all patients was 14.5 months (interquartile range, 6–30 months), and that of patients rendered R0 was 23 months (interquartile range, 10–37 months), in comparison with 7 months (interquartile range, 3–25 months) for those of R1 status (P = .006; log-rank method). Ability to achieve R0 status by synchronous or staged resection was the only factor predictive of survival. Conclusions: The presence of M1 disease per se should not preclude resection of local recurrence, although case selection is problematic.

The explosion in the use of therapeutic laparoscopy during the past decade has focused much research interest on finding a basic scientific support for the clinically apparent attenuation of the stress response to surgery. In particular, the potential impact that attenuation of the immune response to surgery may have on laparoscopy for the cure of malignancy has attracted much attention.A review of the published literature on the stress response to laparoscopic surgery and the impact of laparoscopy on tumor growth was performed.Evidence favors an attenuation of the immune response to surgery with laparoscopic cholecystectomy. Whether this is true also of more major procedures such as laparoscopically assisted colectomy for malignancy is currently unclear. In animal models, tumor growth after laparoscopic surgery is less than after laparotomy and depends on the insufflation agent used.Laparoscopic cholecystectomy appears to be associated with attenuation of the immune response to surgery. The implications of these findings for the future use of laparoscopic surgical techniques for malignant disease remain unclear.

Adult intestinal obstruction is a common surgical emergency to confront the surgical trainee. Rapid diagnosis of the condition and institution of basic management skills are essential to reduce the considerable morbidity and mortality associated with the condition.

OBJECTIVE To determine the proportion of registered trials published in the surgical literature, to compare, in registered trials, the primary outcomes registered with those published and to determine whether outcome-reporting bias favored significant primary outcomes. BACKGROUND Trial protocol registration before patient enrolment for randomized controlled trials (RCTs) is a perquisite for many journals in attempt to decrease publication and selective reporting bias. Analysis of the medical literature demonstrates poor registration rates with discrepancies between reported and registered primary outcomes. This has not been evaluated in contemporary surgical journals. METHODS RCTs were identified for 2009 and 2010 from 10 high-impact factor surgical journals. One investigator identified all RCTs and extracted primary and secondary outcomes, dates of commencement and completion of study, funding source, and trial registration number. Trial registers were searched using the trial registration number for primary and secondary outcomes, dates of commencement and completion of study, and date of registration. Trial registration rates and registration adequacy were recorded. Register and published primary outcomes were then compared. RESULTS A total of 246 papers were analyzed, among which 86 (34.9%) were not registered and 52 (21%) were inadequately registered. Of the 108 adequately registered trials, 32 (29%) had a discrepancy between the published primary outcome and that registered in trial register. In the 24 published studies where it was possible to assess, the discrepancy favored a statistically significant primary outcome in 22 (91.7%) whereas in 2 (8.3%) the discrepancy produced a statistically insignificant result. CONCLUSIONS Less than half of all RCTs published in general surgical journals were adequately registered, and approximately 30% had discrepancies in the registered and published primary outcome with 90% of those assessable favoring a statistically positive result.

Background: The occurrence of anastomotic stricture at the level of the rectum gives rise to three broad therapeutic options, namely major pelvic and abdominal revisional surgery, faecal diversion (stoma), or local revision by transanal approaches (including endoscopic and fluoroscopic). This article updates the current evidence and focuses on the results of the balloon dilatation technique. Methods: A Medline search was carried out using the search terms (dilatation OR dilatation) AND (stricture OR strictures OR stenosis OR stenotic) AND (rectum OR rectal). In an effort to lessen publication bias, articles included at least 10 patients who were consecutively referred for treatment. Results/Conclusion: This review would suggest that probably relatively short strictures have been chosen for balloon dilatation and that the results have had a very low major morbidity (0.45%) and mortality (0%) rate.

Background Abdominoperineal excision of rectum has been associated with poor oncological specimens and high local recurrence rates in comparison with restorative surgery. The role of recent changes in operative position has yet to be evaluated. Objectives This study aimed to determine whether a change in the perineal phase from the Lloyd-Davies position to the prone jackknife position might improve excision margins and oncological outcomes. Methods A single-institution review of a prospectively maintained database comparing the quality of excision and oncological outcomes after abdominoperineal excision in conventional and prone position was performed. Consecutive abdominoperineal excisions performed for adenocarcinoma of the rectum between January 1999 and April 2008 were included. Results Abdominoperineal excision cases were assessed including 63 in the Lloyd-Davies position and 58 in the prone jackknife position. The 5-year local recurrence rate was 5% in the prone jackknife group in comparison with 23% in the Lloyd-Davies group (p = 0.03) by life table analysis. For local recurrence, the most significant and independent risk factors were a favorable effect of having the patient in the prone jackknife position for the perineal phase of abdominoperineal excision (HR 0.2; 95% CI 0.04-0.81) and, unfavorably, a positive circumferential resection margin (HR 7.1; 95% CI 2.4-20). Lymph node involvement (N2) was an independent risk factor for overall survival (HR 4.6; 95% CI 2.1-9.5) and relapse of disease (HR 4.0; 95% CI 0.7-9.4). Limitations This study has some limitations because it is a retrospective review of a prospective database. Conclusion These data suggest that the rate of local recurrence after abdominoperineal excision may be lowered by adaptation of the prone jackknife position.

PURPOSE: The purpose of this study was to analyze the results of brush cytology for the diagnosis of colorectal cancer and compare them with the results of endoscopic biopsy and histologic evaluation of the resected specimen. METHODS: Nine hundred eighteen patients who had brush cytology, endoscopic biopsy, and a definitive resection of a colorectal lesion between 1990 to 2006 were identified from our pathology database. RESULTS: Cytology alone had a sensitivity of 88.2 percent, a specificity of 94.1 percent, a positive predictive value of 98.6 percent, and a negative predictive value of 61.9 percent for the diagnosis of colorectal cancer. Brush cytology always recognized malignant cells, with a positive predictive value of 100 percent. There was no significant difference between brush cytology and biopsy, which had a sensitivity of 86.9 percent, specificity of 98.1 percent, positive predictive value of 99.5 percent, and a negative predictive value of 60.3 percent. Combining the results of brush cytology and biopsy resulted in a statistically significant increase in sensitivity to 97.4 percent (P < 0.001), a significant increase in the negative predictive value to 88.4 percent (P < 0.001), and a significant reduction in the false-negative rate to 0.03 percent (P < 0.001) for the diagnosis of colorectal cancer. CONCLUSIONS: Brush cytology is as accurate as endoscopic biopsy for the diagnosis of colorectal cancer, and combining these two diagnostic modalities resulted in a significant improvement in the definitive diagnosis of cancer, which might reduce the need for further biopsy.

Objective The optimal aim of oncological surgery is to balance cancer outcomes with preservation of function and quality of life. Radical resection (RR) offers the best curative procedure in colorectal cancer but at significant morbidity. Transanal endoscopic microsurgery (TEM) offers an alternative with less morbidity and better function. Its role remains unclear and needs to be established in the light of new emerging trends in rectal cancer. This review aims to evaluate the use of TEM and its limitations. Method PubMed and MEDLINE search was performed. Results Strongest level of evidence (Level II) favoured TEM over RR and laparoscopic resection in term of mortality and morbidity. There was no difference in recurrence at follow-up of 41 and 56 months but neither study was adequately powered to detect a difference in recurrence/survival. Three retrospective case comparisons (Level III) also favoured TEM over RR but were subject to selection bias. Twenty eight published case series (Level IV) reported varying results due to different cancer stages, study population, full excision, adjuvant therapy and treatment indication. The oncological outcomes in TEM are similar to RR in highly selected cases but with far less mortality (near 0%), morbidity, blood loss, hospital stay and genitourinary/gastrointestinal dysfunction. TEM alone (+/− adjuvant therapy) appears sufficient for ‘favourable’ T1 tumours. ‘Unfavourable’ T1 or T2 tumours require adjuvant treatment. TEM should only be used for palliation in T3+ cancers. Seven functional studies reported significant transient dysfunction following TEM with full clinical recovery within a year. TEM is cost-effective providing sufficient cases are performed. Conclusion Significant heterogeneity limits conclusions from current literature. A trial is required. Alternate end-points to local recurrence may be required in assessing the optimal surgical approach, which balances disease control with quality of life, and probability of noncancer related death.

Squamous cell carcinoma (SCC) of the nasopharynx is amongst the most common head and neck cancers. However, distant metastases are clinically underdiagnosed, as demonstrated by significantly higher metastatic rates in autopsy studies, compared to clinical studies. The incidence of metastases continues to rise with improvements in diagnostic imaging, locoregional control and survival. Metastases to the colorectum are extremely rare. This is the first case of nasopharyngeal SCC, metastasising to the rectum. A brief review of the literature is performed, with discussion on the screening, diagnosis and treatment of non-primary / metastatic tumours of the colorectum, from SCC and other primary tumours.

Introduction: Percutaneous radiofrequency ablation (PcRFA) provides alternative means of treating patients with unresectable colorectal liver metastases. We previously reported our initial experience in 30 patients treated with PcRFA. We present the final long-term results in these 30 patients. Methods: The final outcome of the 30 patients treated with PcRFA is reported, 30 months following the initial results published in 2004. Results: Thirty patients (21 males and 9 females), median age 74.5 (44–85) years, underwent PcRFA for 57 lesions in 60 sessions. The final results in this cohort of patients are reported: 28 dead and 2 lost to follow-up. Median follow-up was 22 (3–53) months. Median size was 31 (8–70) mm. Nineteen lesions required repeat PcRFA. Median ablation time per lesion was 12 (4.5–36) min. Eleven patients received chemotherapy pre-PcRFA and 15 received chemotherapy post-PcRFA. Three patients went on to have limited hepatectomies. Complications occurred in 3 (5%) and median hospital stay was 1 (1–7) day. The median hepatic disease-free survival was 12 (95% CI 6.1–17.9) months and actuarial survival was 23.2 (95% CI 18.5–27.8) months. Conclusion: PcRFA is safe and associated with increased disease-free and overall survival in patients with unresectable colorectal hepatic metastases.

Objective: To determine if routine follow-up by magnetic resonance imaging (MRI) improves the detection of resectable local recurrences from colorectal cancer. Summary Background Data: Surgical treatment offers the best prospect of survival for patients with recurrent colorectal cancer. Unfortunately, most cases are often diagnosed at an unresectable stage when traditional follow-up methods are used. The impact of MRI surveillance on the early diagnosis of local recurrences has yet to be ascertained. Methods: Patients who underwent curative surgery for rectal and left-sided colon tumors were included in a program of pelvic surveillance by routine MRI, in addition to the standard follow-up protocol. Cases were then analyzed for mode of diagnosis, resectability, and overall survival. Results: Pelvic recurrence was found in 30 (13%) of the 226 patients studied. MRI detected 26 of 30 (87%) and missed 4 of 30 (13%) cases with local recurrence. Of the latter, 3 were anastomotic recurrences. In 28 (14%) patients, local recurrence was suspected by an initial MR scan but cleared by subsequent MRI or CT-guided biopsy. Recurrent pelvic cancer was diagnosed by MRI with 87% sensitivity and 86% specificity. In 19 (63%) cases, CEA was abnormally elevated, and 9 patients (30%) were symptomatic. Surgical resection was possible in only 6 patients (20%). There was no difference between MRI and conventional follow-up tests in their ability to detect cases suitable for surgery. Conclusions: Pelvic surveillance by MRI is not justified as part of the routine follow-up after a curative resection for colorectal cancer and should be reserved for selectively imaging patients with clinical, colonoscopic, and/or biochemical suspicion of recurrent disease.

In selected patients, local excision of rectal cancer may be an alternative to radical surgery such as abdominoperineal excision of the rectum or anterior resection. Local excision carries lower mortality and morbidity, without the functional disturbance or alteration in body image that can be associated with radical surgery. There are several techniques of local therapy for rectal cancer, with most experience being available in transanal excision. Transanal endoscopic microsurgery is also used but experience with this newer technique is limited. Patient selection is the most important factor in successful local excision, however specific criteria for selecting patients have not been universally accepted. Review of the published literature is difficult because of the variation in adjuvant therapy regimes and follow-up strategies, as well as results reported in terms of local recurrence and survival rates. There is increasing evidence to suggest that local excision should be restricted to patients with T1 stage rectal cancer without high-risk factors. The place for local excision in patients with T2 or high-risk T1 tumours requires prospective, randomised multi-centre trials comparing radical surgery with local excision, with or without adjuvant therapy.

The purpose of our study was to examine all laparoscopic right hemicolectomies performed for cancer in our unit and to compare them with a case-control series of open right hemicolectomies, with emphasis on long-term survival. In a retrospective case-control series of right hemicolectomies, those done laparoscopically were compared with an age-matched and stage-matched series of patients who underwent open surgery. Survival was analyzed with the Kaplan-Meier method. Ninety-nine patients were included in the study, 33 laparoscopic and 66 open. Mean age 69.7 years. Dukes staging was the same between the two groups and mean follow-up period was 65.7 months. There were six laparoscopic conversions. The number of days patients were kept nil by mouth was significantly less in the laparoscopic cohort, with a mean of 2.4 days vs. a mean of 3.65 days (P = 0.005, Mann-Whitney U test). The number of days during which patients required parenteral opiates was significantly less in the laparoscopic cohort, with a mean number of days of 2.5, in contrast to 4.5 days in the open group (P = 0.008, Mann-Whitney U test). When overall survival was compared between the open and laparoscopic groups, no difference was found, with a mean overall survival of 40 months in the laparoscopic cohort and 39.4 months in the open cohort (P = 0.348, log-rank test). Laparoscopic right hemicolectomy for cancer does not compromise long-term survival and affords the advantage of a shorter period of postoperative ileus and decreased analgesia requirements.

We have described one method of approaching this procedure. The laparoscopic-assisted method combines the benefits of laparoscopic mobilization with the advantages of bowel division and reanastomosis under direct vision; the incision also allows a degree of flexibility in the most crucial area, allowing the available option of rectal dissection by laparotomy. The available data suggest that, in terms of histological parameters and early survival and recurrence, the laparoscopic procedure is comparable to laparotomy.5,6,8 The laparoscopic-assisted approach requires an incision of 7 to 10cm and therefore may not yield the benefits of minimally invasive surgery. However, the magnified views provide excellent visualization of the pelvic nerves and the potential for better postoperative functional outcome requires further prospective assessment.

Treatment of rectal cancer has changed dramatically over the past two decades. Radical surgery alone for resectable rectal cancer has been replaced by combined modality therapy. Interest in optimizing sphincter preservation and quality of life motivated surgeons to seek less radical surgery without compromising oncologic principles.

Colorectal cancer is the only commonly curable visceral malignancy. At present in the United Kingdom, approximately 50% of patients with the disease are treated with the reasonable expectation of cure, of whom 50% again can be expected to be alive 5 years later. 1,2 The use of any new treatment modality such as minimal-access surgery cannot be supported in such patients unless it is shown at least to match such a survival profile. Although laparoscopic techniques were first applied to colorectal surgery in 1991, 3–6 the approach has not been widely adopted. This is largely because of concerns over the safety of these techniques in cancer surgery. There is evidence, albeit from nonrandomized studies, suggesting that the margins of excision of colorectal cancer achieved laparoscopically are comparable to those resulting from conventional resection. 7–11 However, the appearance of several reports of early wound recurrence after laparoscopic resection for malignancy, 12,13 including that of Dukes’ A lesions, 14,15 have led to the suggestion that the pattern of disease recurrence may be altered by the laparoscopic approach. Unfortunately, a series of elegant investigations in a variety of animal models have failed to reach a consensus: for every study in which tumor growth was facilitated by laparoscopy, 16,17 there are at least an equivalent number suggesting that growth is attenuated 18–24 or comparable. 19 Although such studies are of interest, the true assessment of the safety of laparoscopic techniques in neoplasia must come from long-term follow-up of patients operated on using such techniques. Such data are at present scarce. The Norfolk surgical group has presented the first 24-month follow-up data from 39 patients in whom the cancer-specific death rate at 24 months was 6%, with an overall recurrence rate of 9%. Importantly, no wound or port-site metastases were detected. The actuarial 3-year survival rate in their series was 92% for node-negative patients and 79% for node-positive patients. 25 The authors commented that such survival and recurrence profiles were similar to those that would be anticipated after open surgery. Similarly, in a small number of other uncontrolled series, Gray et al 26 reported a 22.70% recurrence rate among 22 patients followed up for 24 months and Lumley et al 27 reported a recurrence rate of 6.3% at a median follow-up of 33 months. In the series of Franklin et al, 28 191 patients who had a laparoscopic approach to colorectal cancer were compared stage for stage with a control group of 224 patients undergoing conventional surgery by another group of surgeons; there was no difference in terms of survival or recurrence. Although prospective, this study allowed patients to chose which type of surgery was performed, raising questions regarding selection bias. Lacy et al,29 in a prospective and randomized trial, reported a recurrence rate of 16.1% among 31 laparoscopic-assisted resections after a mean follow-up of 21 months. More recently, Fleshman et al 30 compared survival after laparoscopic abdominoperineal resection with a retrospective control group of patients who underwent an open procedure from several institutions. This study contained data on the radial margin of excision and demonstrated no difference in survival or recurrence between the groups after a median follow-up of 19 months. The randomized trial from the Cleveland Clinic 31 demonstrated no difference in survival or recurrence in 42 patients undergoing laparoscopic resection for cancer after a median follow-up of 1.5 years. The authors reported four cancer-related deaths and no local or port-site recurrences during the follow-up period. These data are reassuring, but the duration of follow-up is variable. Indeed, these studies might be considered premature, because a significant minority of patients were followed up for less than 1 year. In the current study, we aimed to assess the safety of laparoscopic colorectal surgery for carcinoma by a prospective study of stage-for-stage recurrence and death compared with conventional surgery at a minimum follow-up of 2 years.

The management of rectal cancer remains a challenging and controversial area of surgical oncology. The spectre of local recurrence, with its’ poor prognostic and palliative outcomes, is known to be highly dependent on operative technique and to vary widely between surgeons. The roles of radiotherapy and chemotherapy have been the subject of trials for at 30 years and yet no consensus on treatment exists. In this review article we will summarise the evolution of radiotherapy and chemoradiation in the treatment of rectal cancer and evaluate the evidence available for the use of “neoadjuvant” chemoradiation. In particular, the role of adjuvant therapies in the setting of total mesorectal excision will be discussed.

The article is focusing on the first speech of Yahweh – out of the whirlwind – seeking to consider a reorientation presented in the speech (38:1–39:30). Yahweh’s description of the world gives insights that provide a guide for humans to relate to the earth, not as dominators, but as custodians. This fact bears consequences not only for Job and his audience, but is also relevant for the contemporary man.

Summary Background Artificial neural networks are computer programs that can be used to discover complex relations within data sets. They permit the recognition of patterns in complex biological data sets that cannot be detected with conventional linear statistical analysis. One such complex problem is the prediction of outcome for individual patients treated for colorectal cancer. Predictions of outcome in such patients have traditionally been based on population statistics. However, these predictions have little meaning for the individual patient. We report the training of neural networks to predict outcome for individual patients from one institution and their predictive performance on data from a different institution in another region. Methods 5-year follow-up data from 334 patients treated for colorectal cancer were used to train and validate six neural networks designed for the prediction of death within 9, 12, 15, 18, 21, and 24 months. The previously trained 12-month neural network was then applied to 2-year follow-up data from patients from a second institution; outcome was concealed. No further training of the neural network was undertaken. The network's predictions were compared with those of two consultant colorectal surgeons supplied with the same data. Findings All six neural networks were able to achieve overall accuracy greater than 80% for the prediction of death for individual patients at institution I within 9, 12, 15, 18, 21, and 24 months. The mean sensitivity and specificity were 60% and 88%. When the neural network trained to predict death within 12 months was applied to data from the second institution, overall accuracy of 90% (95% Cl 84–96) was achieved, compared with the overall accuracy of the colorectal surgeons of 79% (71–87) and 75% (66–84). Interpretation The neural networks were able to predict outcome for individual patients with colorectal cancer much more accurately than the currently available clinicopathological methods. Once trained on data from one institution, the neural networks were able to predict outcome for patients from an unrelated institution.

The recent application of laparoscopic surgical techniques to colorectal resection is controversial, and the value of this new treatment modality is, as yet, unclear. The laparoscopic approach may confer benefit to the patient in terms of reduced wound-related morbidity, shorter duration of ileus and decreased hospital stay [6, 7, 12, 17, 20, 29]. However, the oncological safety of laparoscopic techniques is unproven. Histological examination of resected specimens has provided data suggesting that the lymph node clearance and excision margins achieved laparoscopically may be comparable to those obtained using conventional surgical techniques [7, 8, 12, 24, 25]. However, the loco-regional recurrence rates consequent upon the laparoscopic approach are not yet known. There are also reports of wound recurrence following laparoscopic surgery, some of which have occurred after “curative excision” of early cancers, and these have yet to be adequately explained [18, 28]