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Background Accurate quality of life (QoL) data and functional results after cancer surgery are lacking for older patients. The international, multicenter Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery (GOSAFE) Study compares QoL before and after surgery and identifies predictors of decline in QoL. Methods GOSAFE prospectively collected data before and after major elective cancer surgery on older adults (≥70 years). Frailty assessment was performed and postoperative outcomes recorded (30, 90, and 180 days postoperatively) together with QoL data by means of the three-level version of the EuroQol five-dimensional questionnaire (EQ-5D-3L), including 2 components: an index (range = 0-1) generated by 5 domains (mobility, self-care, ability to perform the usual activities, pain or discomfort, anxiety or depression) and a visual analog scale. Results Data from 26 centers were collected (February 2017-March 2019). Complete data were available for 942/1005 consecutive patients (94.0%): 492 male (52.2%), median age 78 years (range = 70-95 years), and primary tumor was colorectal in 67.8%. A total 61.2% of all surgeries were via a minimally invasive approach. The 30-, 90-, and 180-day mortality was 3.7%, 6.3%, and 9%, respectively. At 30 and 180 days, postoperative morbidity was 39.2% and 52.4%, respectively, and Clavien-Dindo III-IV complications were 13.5% and 18.7%, respectively. The mean EQ-5D-3L index was similar before vs 3 months but improved at 6 months (0.79 vs 0.82; P Conclusions GOSAFE shows that older adults’ preoperative QoL is preserved 3 months after cancer surgery, independent of their age. Frailty screening tools, patient-reported outcomes, and goals-of-care discussions can guide decisions to pursue surgery and direct patients’ expectations.

Pelvic floor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic floor imaging include fluoroscopic defecography, magnetic resonance defecography, and pelvic floor ultrasound. This collaboration opinion paper was developed by representatives from multiple specialties involved in care of patients with pelvic floor dysfunction (radiologists, urogynecologists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The final draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA).

Few studies have confirmed a benefit for adjuvant chemotherapy (aCTX) in stage II colon cancer. We used the National Cancer Database to explore the use and efficacy of aCTX in patients with both normal-risk (NR) and high-risk (HR) young stage II colon cancer.We identified patients with stage II colon cancer who underwent colectomy between 2010 and 2015. HR patients included at least: lymphovascular or perineural invasion, 12 lymph nodes, poor/un-differentiation, T4, or positive margins. Rates of aCTX by age and risk were calculated, and adjusted factors associated with aCTX were identified. Overall survival was estimated using the Kaplan-Meier method and Cox multivariable analyses for patients 50 years.Among the 81,066 stage II patients who underwent colectomy, 6093 (7.5%) were 50 years old. Of these, 2669 patients were HR. Thirty percent of NR and almost 60% of HR patients 50 years received aCTX, compared with 8% and 23% of patients50 years (P .001). In NR patients 50 years, 35.3% with microsatellite-stable tumors and 18% with microsatellite unstable tumors received aCTX (P .001), whereas 63.6% and 43.2%, respectively, of HR patients did (P .001). The most significant multivariable predictors of aCTX were risk status and age. On univariate analysis, there was no survival benefit associated with aCTX in patients 50 years. Multivariate analysis failed to demonstrate a survival benefit for aCTX for either group (HR, 0.97; P = .84; NR, 0.1.03; P = .90).Young patients with HR and NR colon cancer received aCXT more frequently than older patients with no demonstrable survival benefit. This bears further evaluation to avoid the real risks of over-treatment in this increasing population.

Evidence suggests that elective primary colon resection (ePCR) in patients with asymptomatic colon tumors and unresectable metastases is not required and may expose patients to unnecessary operative risk.Stage IV colon cancer patients with liver metastases from 2000 to 2011 were identified with SEER-Medicare data. Liver-based therapy or urgent/emergent colectomies were excluded. Chemotherapy alone was compared to ePCR ± chemotherapy. Univariate and multivariate analyses were used to identify predictors of ePCR. Multivariate Cox regression compared survival.5139 patients were identified. The ePCR rate decreased over time; 84% underwent ePCR in 2000, compared to 52% in 2011 (p 0.001). In multivariate analysis, older patients were more likely to undergo ePCR, as were patients from rural areas (OR 1.65, p 0.001). The odds of PCR in high poverty areas (10%) were almost 25% higher than those in low poverty areas (OR 1.23, p = 0.03). African-Americana were less likely to undergo PCR than Caucasians (OR 0.76, p = 0.01). In multivariate survival analysis, PCR was associated with a significant survival benefit (HR 0.59, p 0.001).Although ePCR is not recommended with unresectable metastases and the rate has decreased significantly, over 50% of patients with untreated hepatic metastases underwent ePCR in 2011. Disparities exist in use of ePCR that are likely multifactorial and deserve further study.

Fecal incontinence (FI), or “recurrent uncontrolled passage of fecal material for at least 1 month,” is a life-limiting condition that is frequently under-reported. Continence occurs by coordinated function of the sphincter complex contraction/relaxation, pelvic floor musculature, hemorrhoidal tissue, and neurologic feedback in response to the fecal matter present in the rectal vault. Therefore, there a number of mechanisms necessary for continence that can be dysfunctional in this condition. The complexity of the problem requires the surgeon to be familiar with all treatment options available since multiple therapies can be combined to optimize results. Treatment should be individualized.

Patient selection and preoperative evaluation play a vital role in the application of sacral neuromodulation (SNM) to fecal incontinence (FI). The history and physical should elucidate the nature of the incontinence, including duration, severity, type of leakage, as well as associated pathology (e.g., urinary incontinence, prolapse, etc.). Additionally, the use of a validated incontinence scoring system in obtaining an objective measure is recommended as a way to monitor an individual patient’s response to treatment over time. Despite dramatic success with SNM for severe incontinence, medical therapies should remain first-line treatment, especially for mild to moderate FI. In addition to idiopathic causes of FI, small series have reported successes in patients with disrupted anal sphincters, spinal cord injury, rectal prolapse, and low anterior resection syndrome. In general, studies on sacral neuromodulation have failed to identify consistent predictors correlating with response to treatment. Two considerations unique to SNM, cardiac pacemakers and anomalous anatomy, are not absolute contraindications but do mandate thorough preoperative planning and counseling.

Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.

Colonoscopy is a common procedure performed for screening, diagnostic, or therapeutic indications; nevertheless, it is an invasive procedure that has associated risks. Complications of colonoscopy can be divided into four main categories: (1) bleeding, (2) postpolypectomy syndrome, (3) perforation, and (4) rarely, solid organ injury. In this review, we discuss strategies to avoid and treat complications of colonoscopy. Diligent biopsy and use of electrocautery and avoiding looping and blind advancement of the colonoscope minimize the risk of these complications. Management of complications ranges from non-operative conservative management, to minimally invasive endoscopic or laparoscopic techniques, to operative exploration.

Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the frequency with which intestinal stomas are created, stoma-related complications remain common and are associated with significant morbidity as well as cost. Some of the most prevalent complications of stoma formation which will be detailed in this article include peristomal skin complications, retraction, stomal necrosis, stomal stenosis, prolapse, bleeding, dehydration from high ostomy output, and parastomal hernia. The authors will review these common complications, detail means to avoid or prevent them, and outline recommendations for management.

Objective: Older patients with cancer value functional outcomes as much as survival, but surgical studies lack functional recovery (FR) data. The value of a standardized frailty assessment has been confirmed, yet it's infrequently utilized due to time restrictions into everyday practice. The multicenter GOSAFE study was designed to (1) evaluate the trajectory of patients' quality of life (QoL) after cancer surgery (2) assess baseline frailty indicators in unselected patients (3) clarify the most relevant tools in predicting FR and clinical outcomes. This is a report of the study design and baseline patient evaluations. Materials & Methods: GOSAFE prospectively collected a baseline multidimensional evaluation before major elective surgery in patients (≥70 years) from 26 international units. Short−/mid−/long-term surgical outcomes were recorded with QoL and FR data. Results: 1003 patients were enrolled in a 26-month span. Complete baseline data were available for 977(97.4%). Median age was 78 years (range 70–94); 52.8% males. 968(99%) lived at home, 51.6% without caregiver. 54.4% had ≥ 3 medications, 5.9% none. Patients were dependent (ADL < 5) in 7.9% of the cases. Frailty was either detected by G8 ≤ 14(68.4%), fTRST ≥ 2(37.4%), TUG > 20 s (5.2%) or ASAIII-IV (48.8%). Major comorbidities (CACI > 6) were detected in 36%; 20.9% of patients had cognitive impairment according to Mini-Cog. Conclusion: The GOSAFE showed that frailty is frequent in older patients undergoing cancer surgery. QoL and FR, for the first time, are going to be primary outcomes of a real-life observational study. The crucial role of frailty assessment is going to be addressed in the ability to predict postoperative outcomes and to correlate with QoL and FR.

Current guidelines recommend the evaluation of at least 12 lymph nodes (LNs) in the pathologic specimen following surgery for colorectal cancer (CRC). We sought to examine the role of colorectal specialization on nodal identification.We conducted a retrospective cohort study using SEER-Medicare data to examine the association between colorectal specialization and LN identification following surgery for colon and rectal adenocarcinoma between 2001 and 2009. Our dataset included patients65 years who underwent surgical resection for CRC. We excluded patients with rectal cancer who had received neoadjuvant therapy. The primary outcome measure was the number of LNs identified in the pathologic specimen following surgery for CRC. Multivariate analysis was used to identify the association between surgical specialization and LN identification in the pathologic specimen.In multivariate analysis, odds of an adequate lymphadenectomy following surgery with a colorectal specialist were 1.32 and 1.41 times greater for colon and rectal cancer, respectively, than following surgery by a general surgeon (p 0.001). These odds increased to 1.36 and 1.58, respectively, when analysis was limited to board-certified colorectal surgeons. Hospital factors associated with ≥12 LNs identified included high-volume CRC surgery (colon OR 1.84, p 0.001; rectal OR 1.78, p 0.001) and NCI-designated Cancer Centers (colon OR 1.75, p 0.001; rectal OR 1.64; p = 0.007).Colorectal specialization and, in particular, board-certification in colorectal surgery, is significantly associated with increased LN identification following surgery for colon and rectal adenocarcinoma since the adoption of the 12-LN guideline in 2001.

AIM It is recognized that higher surgeon volume is associated with improved survival in colorectal cancer. However, there is a paucity of national studies that have evaluated the relationship between surgical specialization and survival. METHOD We used the Surveillance, Epidemiology, and End Results Medicare cancer registry to examine the association between colorectal specialization (CRS) and disease-specific survival (DSS) between 2001 and 2009. A total of 21,432 colon cancer and 5893 rectal cancer patients who underwent elective surgical resection between 2001 and 2009 were evaluated. Univariate and multivariate Cox survival analysis was used to identify the association between surgical specialization and cancer-specific survival. RESULTS Colorectal specialists performed 16.3% of the colon and 27% of the rectal resections. On univariate analysis, specialization was associated with improved survival in Stage II and Stage III colon cancer and Stage II rectal cancer. In multivariate analysis, however, CRS was associated with significantly improved DSS only in Stage II rectal cancer [hazard ratio (HR) 0.70, P = 0.03]. CRS was not significantly associated with DSS in either Stage I (colon HR 1.14, P = 0.39; rectal HR 0.1.26, P = 0.23) or Stage III (colon HR 1.06, P = 0.52; rectal HR 1.08, P = 0.55) disease. When analysis was limited to high volume surgeons only, the relationship between CRS and DSS was unchanged. CONCLUSIONS CRS is associated with improved DSS following resection of Stage II rectal cancer. A combination of factors may contribute to long-term survival in these patients, including appropriate surgical technique, multidisciplinary treatment decisions and guideline-adherent surveillance. CRS probably contributes positively to these factors resulting in improved survival.

During the past several decades, anal physiology testing has afforded us a more complete understanding of the complex interactions between pelvic anatomy and physiology. Techniques have been improved and validated in both normal volunteers and in states of disease. This chapter will give a detailed overview of the differing methods of anal physiology testing and provide clinical correlations as to when these tests may be useful, or conversely, in which situations clinical judgment should supersede testing.

With increased use of explosive devices in warfare, anal trauma is often seen coupled with more complex pelviperineal injury. While the associated mortality is high, casualties that survive are often left with disabling fecal incontinence from damage to the anosphincteric complex. After resolution of the acute insult, the initial evaluation mandates a thorough physical exam, including endoscopic evaluation with rigid proctoscopy and flexible sigmoidoscopy, as well as adjunctive testing, specifically anal manometry and endoanal ultrasound. First-line therapy favors bulking agents and antidiarrheals, in conjunction with biofeedback, due to a minimal risk profile. Surgical options range from direct sphincter repairs to complex anosphincteric reconstruction with widely variable results. Most recently, burgeoning therapies in the treatment of fecal incontinence, including sacral nerve stimulation and magnetic anal sphincters, offer excellent alternatives with promising long-term outcomes. In summation, the goal of all interventions is the re-establishment of bowel continence, but, in its absence, permanent fecal diversion for devastating fecal incontinence is a reasonable option with excellent patient satisfaction scores.

Perineal proctosigmoidectomy or the Altemeier procedure has been marginalized to the elderly due to high recurrence rates. However, a review of the literature suggests that this technique may be unfairly scrutinized due to outdated techniques and severe heterogeneity among the earlier published reports. In fact, recent studies show that the perineal proctosigmoidectomy with levatorplasty is safe and effective, has a favorably low recurrence rate, and should also be considered in healthy, young patients.

Fecal incontinence is a devastating condition, vastly under-reported, and may affect up to 18% of the population. While conservative management may be efficacious in a large portion of patients, those who are refractory will likely benefit from appropriate surgical intervention. There are a wide variety of surgical approaches to fecal incontinence management, and knowledge and experience are crucial to choosing the appropriate procedure and maximizing functional outcome while minimizing risk. In this article, we provide a comprehensive description of surgical options for fecal incontinence to help the clinician identify an appropriate intervention.

Social media is a necessary component of the practice of surgery. Each surgeon must embrace the power and potential of social media and serve as a guide or content expert for patients and other health care providers to facilitate and share responsible use of the various media available. Social media facilitates rapid communication of information not only across providers but also between patients and providers. The power of social media has the potential to improve consultation and collaboration, facilitate patient education, and expand research efforts; moreover, by harnessing its potential, the appropriate use of many of the avenues of social media also can be used to disseminate campaigns to increase disease awareness and communicate new research findings and best-practice guidelines. Because its reach is so broad within as well as outside the censorship of medical experts, professional oversight and engagement is required to maximize responsible use. Staying consistent with our history of surgery, rich in innovation and technologic advancement, surgeons must get to the front of this evolving field and direct the path of social media as it applies to the practice of surgery rather than take a passive role.

To a large degree, the development of transanal endoscopic microsurgery (TEM) was catalyzed by the revolution started by the widespread adoption of minimally invasive surgery and laparoscopic cholecystectomy. TEM was developed by Professor Gerhard Buess in Tubingen, Germany, as a response to limitations in the ability of transanal surgery to manage proximal rectal lesions. Professor Buess developed a tool which provided substantial advantages to standard transanal excision. In 1983, following successful animal trials, Buess published a report using his innovative proctoscope to remove a rectal adenoma. The use of this technique subsequently expanded in the USA. The technology has evolved, now with the original design being augmented with a laparoscopic attachment for overhead viewing. In addition, several other innovative platforms for transanal endoscopic surgery (TES) have been developed. This chapter will serve to outline the technique, indications, outcomes, and pitfalls of the various TES techniques for the management of rectal surgery. Finally, we will discuss some newer innovative and thought-provoking uses of the TES platform.

Complications of colonoscopy can be divided into three main categories: bleeding, perforation, and postpolypectomy syndrome. Several techniques can be undertaken to decrease the likelihood of complications such as diligent use of electrocautery, avoidance of blind pushing while performing colonoscopy, and deceasing looping. When complications do occur, management varies from conservative to minimally invasive techniques to operative exploration with stoma. As surgery becomes less invasive so too has the management of complications with control of bleeding and repair of perforation becoming less invasive with time. Management algorithms for bleeding and perforation secondary to diagnostic and therapeutic colonoscopy are presented with this chapter.

Perianal manifestations of CD disease are usually chronic in nature, and often characterized by waxing and waning symptoms. The goals of treatment are typically achieved through multimodal management, which minimizes ablative surgical intervention and preserves the sphincter complex [1, 2]. While there is a spectrum of severity in the observed impact of perianal CD, even the minor issues of skin tags and fissuring can present the clinician with difficult decisions in management. In this chapter, we have attempted to provide some clarity to the decision process.

In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.

The impact of pregnancy on the course of Crohn disease is largely unknown. Retrospective surveys have suggested a variable effect, but there are limited population-based clinical data. We hypothesized pregnant women with Crohn disease will have similar rates of surgical disease as a nonpregnant Crohn disease cohort.International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify female Crohn patients from all patients admitted using the Nationwide Inpatient Sample (1998-2009). Women were stratified as either pregnant or nonpregnant. We defined Crohn-related surgical disease as peritonitis, gastrointestinal hemorrhage, intra-abdominal abscess, toxic colitis, anorectal suppuration, intestinal-intestinal fistulas, intestinal-genitourinary fistulas, obstruction and/or stricture, or perforation (excluding appendicitis).Of the 92,335 women admitted with a primary Crohn-related diagnosis, 265 (0.3%) were pregnant. Pregnant patients were younger (29 versus 44 y; P0.001) and had lower rates of tobacco use (6% versus 13%; P0.001). Pregnant women with Crohn disease had higher rates of intestinal-genitourinary fistulas (23.4% versus 3.0%; P0.001), anorectal suppuration (21.1% versus 4.1%; P0.001), and overall surgical disease (59.6% versus 39.2%; P0.001). On multivariate logistic regression analysis controlling for malnutrition, smoking, age, and prednisone use, pregnancy was independently associated with higher rates of anorectal suppuration (odds ratio [OR], 5.2; 95% confidence interval [CI], 3.8-7.0; P0.001), intestinal-genitourinary fistulas (OR, 10.4; 95% CI, 7.8-13.8; P0.001), and overall surgical disease (OR, 2.9; 95% CI, 2.3-3.7; P0.001).Pregnancy in women with Crohn disease is a significant risk factor for Crohn-related surgical disease, in particular, anorectal suppuration and intestinal-genitourinary fistulas.

The debate regarding optimal preparation of the patient for elective colon surgery spans numerous surgical generations. Mechanical bowel preparation prior to elective colorectal surgery has the observational benefit in reducing anastomotic leakage and infectious complications. Several newer studies have now questioned the need for any kind of mechanical bowel preparation and have certainly challenged these previous notions. Therefore, this article will evaluate the evidence and attempt to identify the ideal bowel prep and evaluate the role, if any, of reducing the incidence of anastomotic leak and surgical site infections.

The surgical approach to treating fecal incontinence is complex. After optimal medical management has failed, surgery remains the best option for restoring function. Patient factors, such as prior surgery, anatomic derangements, and degree of incontinence, help inform the astute surgeon regarding the most appropriate option. Many varied approaches to surgical management are available, ranging from more conservative approaches, such as anal canal bulking agents and neuromodulation, to more aggressive approaches, including sphincter repair, anal cerclage techniques, and muscle transposition. Efficacy and morbidity of these approaches also range widely, and this article presents the data and operative considerations for these approaches.

The development of an academic surgical career can be an overwhelming prospect, and one that is not intuitive. Establishing a structured plan and support structure is critical to success. Starting a successful academic surgical career begins with defining one's academic goals within several broad categories: personal goals, academic goals, research goals, educational goals, and financial goals. Learning the art of self-promotion is the means by which many of these goals are achieved. It is important to realize that achieving these goals requires a delicate personal balance between work and home life, and the key ways in which to achieve success require establishment of well thought-out goals, a reliable support structure, realistic and clear expectations, and frequent re-evaluation.

Crohn disease involves the perineum and rectum in approximately one-third of patients. Symptoms can range from mild, including skin tags and hemorrhoids, to unremitting and severe, requiring a proctectomy in a small, but significant, portion. Fistula-in-ano and perineal sepsis are the most frequent manifestation seen on presentation. Careful diagnosis, including magnetic resonance imaging or endorectal ultrasound with examination under anesthesia and aggressive medical management, usually with a tumor necrosis factor-alpha, is critical to success. Several options for definitive surgical repair are discussed, including fistulotomy, fibrin glue, anal fistula plug, endorectal advancement flap, and ligation of intersphincteric fistula tract procedure. All suffer from decreased efficacy in patients with Crohn disease. In the presence of active proctitis or perineal disease, no surgical therapy other than drainage of abscesses and loose seton placement is recommended, as iatrogenic injury and poor wound healing are common in that scenario.

Introduction Work rules have changed medical education. Knowledge previously acquired by experience must now be actively taught to avoid prolonging the training period. We report the feasibility of and clinical clerk opinions regarding a novel simulated floor management course to teach patient care concepts required on the surgical wards. Methods We created a hospital ward with simulators exhibiting physical exam findings and active vital signs. Surgical clerks gathered data during “morning rounds,” wrote notes, and provided care. An acute event allowed students to participate in active evaluation and treatment. Findings and plans were communicated to their “chief resident,” a surgical attending. We distributed a survey to participants to determine attitudes and opinions about the course. Results The course required five faculty, two medical educators, four surgical house staff, and 2.5 h to accommodate 40–50 students. Faculty and surgical house staff provided guidance and feedback on clinical skills. Fifty students completed the survey (56% response rate). Most clinical clerks thought that the simulated floor management course improved their understanding of medical management of surgical issues (66%) and their documentation skills (78%). Clinical clerks reported that attending involvement made the experience more valuable (89%) and was not intimidating (66%). Most expressed an interest in participating in more clinical scenarios (72%). Conclusions A simulation course for teaching patient care concepts is feasible and regarded positively by clinical clerk participants. Further development and use of such simulated patient care exercises may be an effective adjunct for training future house staff and hospital staff in patient care in a time of shifting work hour paradigms.

Treatment decisions for colorectal cancer vary based on lymph node status. While some histopathological features of the primary tumor correlate with lymph node spread, the relative influences of these risk factors are not well quantified. This study aims to systematically review published studies relating histopathological features of primary colorectal cancer to the presence of lymph node metastases and to determine how reliable certain factors might be at predicting nodal metastasis when only the primary lesion is available for study. Inclusive literature search using EMBASE and Ovid MEDLINE databases plus manual reference checks of all articles correlating lymphatic spread with colorectal cancer (any T stage) from 1984 to mid-2008 was performed. This search generated two levels of screening utilized on 602 citations, yielding 123 articles for full review. Data reported from 76 articles were chosen. The relative influence of each histopathological feature on the likelihood of lymphatic metastases was determined. Fixed-effects meta-analysis was performed, and results were reported as Mantel–Haenszel odds ratios (OR). Of 42 histopathological features analyzed, only 40.4% were reported in >2 articles. The positive predictive values for the top quartile of most frequently reported risk factors were 25.5–86.4%. Among the commonly reported histopathological findings, lymphatic invasion (OR, 8.62) significantly outperformed tumor depth (T2 vs. T1; OR, 2.62) and overall differentiation (OR, 2.38) in predicting nodal spread. For the rectal cancer subset, risk factors differed from the overall colorectal group in predictive ability; poor differentiation at the invasive front (OR, 6.08) and tumor budding (OR, 5.82) were the most predictive. This literature search is limited by the small number of studies examining only rectal cancers and the potential changes in histological and/or surgical techniques over the study period. No single histopathological feature of colorectal cancer reliably predicted lymph node metastases. Several risk factors that correlate highly with nodal disease are not routine components of standard pathology reports. Until further research establishes histopathological or molecular patterns for predicting lymph node spread, caution should be exercised when basing treatment decisions solely on these factors.

Management of complicated diverticulitis continues to evolve. The dogma of decades past has undergone reevaluation in the wake of modern techniques and critical care management. This article attempts to address the following questions: (1) what defines “complicated diverticulitis”; (2) when is an intervention beyond medical management indicated; and (3) what currently (based on the type of complication) appears to be the optimal intervention?

The management of complex cryptoglandular fistula has concerned surgeons for millennia. The need to control infection and extirpate the fistula while maintaining the continence mechanism has yielded the development of multiple approaches to fistula management. Seton placement is perhaps the oldest approach to initial control of sepsis and long-term fistula management. Fistulotomy is a time-honored, highly successful approach to fistula, but it can be associated with a varying and significant impact on continence. The advancement flap was developed as a sphincter-sparing method of definitive closure of the internal opening, but this approach is technically difficult and associated with varying degrees of success and impact on continence. The anal fistula plug was introduced as a safe, easy sphincter-sparing approach with excellent early success. Longer-term results and diverse reports, however, have shown disappointing overall success. Newer surgical approaches, such as ligation of the intersphincteric fistula tract, have focused on eradication of the fistula tract and cryptoglandular source in the intersphincteric plane. This method has shown early, promising success but remains to be validated. This technique has also been modified by the use of biological mesh to augment repair and appears promising. The range of approaches and outcomes continues to reinforce the fact that no one approach is the magic bullet. Surgeons need to maintain an armamentarium of approaches to complex fistulae and individualize treatment. Further randomized trials and appropriate, objective assessment of new biological approaches need to be conducted to help guide our treatment choices and improve outcomes.

Complications after open or laparoscopic approaches to ventral or incisional hernia repair with mesh span a wide range of severity. Intraoperative injuries to the bowel are rare but may necessitate a change in the operative plan. Postoperative complications are comprised of those common to all general surgery, for example, thromboembolism and superficial surgical site infection, and are typically managed no differently. Unique to recovery from hernia surgery however can be increased pain after mesh placement, seroma related to large dissection planes, infections of the mesh, as well as pulmonary insufficiency due to changes or loss in abdominal domain. Laparoscopic approaches to ventral or incisional hernia have dramatically affected the morbidity of surgery but may introduce complications unique to that approach. More serious long-term complications include chronic pain, chronic mesh infections, as well as the rare, but highly morbid, enterocutaneous fistula involving mesh. Complications such as these, likely require revisional surgery for resolution. Finally, hernia recurrence remains a low, but reliable risk, and although newer techniques continue to evolve and promise better results, the perfect approach to hernia surgery has yet to be defined. Time and experience will continue to shape our attempts at better hernia surgery.

This study investigates the role of tumor nitric oxide (NO) and vascular regulation in tumor ulceration following high-dose tumor necrosis factor-α (TNF) treatment. Using TNF-responsive (MethA) and nonresponsive (LL2) mouse tumors, tumor NO concentration was measured with an electrochemical sensor and tumor blood flow by Doppler ultrasound. Mice were also pretreated with a selective inducible nitric oxide synthase (iNOS) inhibitor, 1400 W. Tumors harvested from TNF-treated mice were cryosectioned and immunostained for murine macrophages, or/and iNOS. MethA tumor-bearing mice were depleted of macrophages. Pre- and post-TNF tumor NO levels were measured continuously, and mice were followed for gross tumor response. In MethA tumors, TNF caused a 96% response rate, and tumor NO concentration doubled. Tumor blood flow decreased to 3% of baseline by 4 hr and was sustained at 24 hr and 10 days post-TNF. Selective NO inhibition with 1400 W blocked NO rise and decreased response rate to 38%. MethA tumors showed tumor infiltration by macrophages post-TNF and the pattern of macrophage immunostaining overlapped with iNOS immunostaining. Depletion of macrophages inhibited tumor NO increase and response to TNF. LL2 tumors had a 0% response rate to TNF and exhibited no change in NO concentration. Blood flow decreased to 2% of baseline by 4 hr, recovered to 56% by 24 hr and increased to 232% by 10 days. LL2 tumors showed no infiltration by macrophages post-TNF. We conclude that TNF causes tumor infiltrating, macrophage-derived iNOS-mediated tumor NO rise and sustained tumor blood flow shutdown, resulting in tumor ulceration in the responsive tumor. © 2008 Wiley-Liss, Inc.

Robotics has its roots back to ancient human history. The current conception of the surgical robot began with NASA, as a government project in telepresence surgery for use in remote battlefield surgery. The concept then quickly evolved into what we use today in the operating room. The da Vinci robot, the most commonly used robotic platform, is now pervasively used for all types of surgery. This chapter serves to explore the origins of the surgical robot and provide a brief overview of its current and, perhaps, future applications.

Study objective To evaluate whether suction or water seal is superior in the management of chest tubes after pulmonary resection. Design A prospective, randomized, controlled trial. After an initial, brief period of suction, patients were randomized to water seal or − 20 cm H 2 O suction. Setting University hospital. Patients Sixty-eight patients who underwent wedge resection, segmentectomy, or lobectomy were included in the study. Those patients who underwent reoperative surgery or lung volume reduction surgery were excluded. Results There were 34 patients in each group. The two groups were evenly matched for age, sex, operation performed, severity of lung disease, and nutritional status. Fifteen patients in each group (44%) had an air leak at the completion of surgery. The duration of the air leak was shorter in the water seal group than in the suction group (mean ± SEM, 1.50 ± 0.32 days vs 3.27 ± 0.80 days, respectively; p = 0.05). The mean times to removal of chest tubes were 3.33 ± 0.35 days in the water seal group and 5.47 ± 0.98 days in the suction group (p = 0.06). The length of stapled parenchyma was measured for each patient and averaged 24.9 cm for the water seal group and 18.5 cm for the suction group (p = 0.18). When corrected for the length of staple lines, the duration of air leaks and days with chest tube were dramatically lower in the water seal group (p = 0.02 and p = 0.02, respectively). Conclusion Placing chest tubes on water seal after a brief period of suction after pulmonary resection shortens the duration of the air leak and likely decreases the time that the chest tubes remain in place. Adoption of this practice may result in lower morbidity and lower hospital costs.

Parastomal hernia is a prevalent problem and treatment can pose difficulties due to significant rates of recurrence and morbidities of the repair. The current standard of care is to perform parastomal hernia repair with mesh whenever possible. There exist multiple options for mesh reinforcement (biologic and synthetic) as well as surgical techniques, to include type of repair (keyhole and Sugarbaker) and position of mesh placement (onlay, sublay, or intraperitoneal). The sublay and intraperitoneal positions have been shown to be superior with a lower incidence of recurrence. This procedure may be performed open or laparoscopically, both having similar recurrence and morbidity results. Prophylactic mesh placement at the time of stoma formation has been shown to significantly decrease the rates of parastomal hernia formation.

Colon cancer remains a significant clinical problem worldwide and in the United States it is the third most common cancer diagnosed in men and women. It is generally accepted that most malignant neoplasms of the colon arise from precursor adenomatous polyps. This stepwise progression of normal epithelium to carcinoma, often with intervening dysplasia, occurs as a result of multiple sequential, genetic mutations-some are inherited while others are acquired. Malignant polyps are defined by the presence of cancer cells invading through the muscularis mucosa into the underlying submucosa (T1). They can appear benign endoscopically but the presence of malignant invasion histologically poses a difficult and often controversial clinical scenario. Emphasis should be initially focused on the endoscopic assessment of these lesions. Suitable polyps should be resected en-bloc, if possible, to facilitate thorough evaluation by pathology. In these cases, proper attention must be given to the risks of residual cancer in the bowel wall or in the surrounding lymph nodes. If resection is not feasible endoscopically, then these patients should be referred for surgical resection. This review will discuss the important prognostic features of malignant polyps that will most profoundly affect this risk profile. Additionally, we will discuss effective strategies for their overall management.

The surgical approach to elderly patients has undergone a major shift over the last two decades with the advent and widespread acceptance of a minimally invasive approach. The indications for laparoscopy in the elderly have shifted from a contraindication to a primary indication based on data and experience. The assessment of the elderly patient is based on physiologic age rather than chronologic age, but initial assessment is still critical in determining fitness for surgery. Ultimately, this is based primarily on known comorbidities and functional assessment. Laparoscopy in the elderly has been increasing over time, and data has been accrued that details the same advantages of an enhanced recovery protocol afforded in younger patients are also seen when using the laparoscopic approach in the elderly. Pneumoperitoneum induces multiple physiologic and hemodynamic changes, the sequelae of which may be accentuated in the elderly with increasing comorbid conditions.

Perioperative fluid management of the colorectal surgical patient has evolved significantly over the last five decades. Older notions espousing aggressive hydration have been shown to be associated with increased complications. Newer data regarding fluid restriction has shown an association with improved outcomes. Management of perioperative fluid administration can be considered in three primary phases: In the preoperative phase, data suggests that avoidance of preoperative bowel preparation and avoidance of undue preoperative dehydration can improve outcomes. Although the type of intraoperative fluid given does not have a significant effect on outcome, data do suggest that a restrictive fluid regimen results in improved outcomes. Finally, in the postoperative phase of fluid management, a fluid-restrictive regimen, coupled with early enteral feeding also seems to result in improved outcomes.

The optimal delivery method in patients with Crohn's disease is unknown, and there is no large-scale evidence on which to base decisions.The aim of this study was to compare delivery methods and outcomes in patients with and without Crohn's disease.The Nationwide Inpatient Sample and International Classification of Diseases, Ninth Revision codes were used to identify childbirth deliveries. Patients were stratified by the presence or absence of Crohn's disease and perianal disease (anorectal fistula or abscess, rectovaginal fistula, anal fissure, and anal stenosis).A large population-cohort database was used for the analysis.The primary outcomes measured were cesarean delivery and perineal lacerations.Of 6,794,787 pregnant women who delivered, 2882 had a diagnosis of Crohn's disease. Rates of cesarean delivery were higher in patients who had Crohn's disease with (83.1%) and without (42.8%) perianal disease in comparison with patients who did not have Crohn's disease with (38.9%) and without (25.6%) perianal disease (p0.001). Rates of 4th degree perineal lacerations were similar between patients who had or did not have Crohn's disease without perianal disease (1.4% vs 1.3%), but these rates increased significantly in patients with perianal disease (12.3%, p0.001). On multivariate analysis, perianal disease (OR, 10.9; 95% CI, 8.3-4.1; p0.001) and smoking (OR, 1.6; 95% CI, 1.5-1.7; p0.001) were independently associated with higher rates of 4th degree laceration. Crohn's disease was not independently associated with 4th degree laceration.This was a retrospective study with the inherent limitations of large databases.Patients with Crohn's disease have higher rates of cesarean delivery. Perianal disease predicts severe perineal laceration independent of the presence of Crohn's disease. In the absence of perianal disease, the method of delivery in women with Crohn's disease should be predicated on obstetric indication.

The care of elderly patients with colorectal problems introduces significant complexity even to basic management. Preoperative assessment of this patient is essential to optimizing treatment, and you should consider their physiologic, not chronologic age. Identification of risk factors should guide surgical planning. Issues related to postoperative function and surgical technique are often different in the elderly compared to younger patients. Other matters regarding informed consent are also often complex and must take into consideration patient competence and family issues. Screening recommendations for modalities such as colonoscopy may apply differently to the elderly patient and current guidelines provide a rationale for appropriate selection. Optimizing surgical outcomes in the elderly patient requires a holistic, judicious, and compassionate approach.

Rectal resection is the most common treatment of rectal cancer and inflammatory bowel disease. The surgical techniques for removing and reconstructing the rectum have evolved significantly over the past 50 years. Technological advances including retractors, stapling devices, energy delivery systems, and minimally invasive approaches, as well as the nerve-sparing total mesorectal excision, have revolutionized the surgical treatment. Surgical exposure and precise technique affect the ability to preserve the pelvic autonomic nerves, directly influencing postoperative urinary and sexual function. The complex interplay between all these factors demands attention because of the associated short-term and long-term impact on patient quality of life.

The Accreditation Council for Graduate Medical Education work rules have forced programs to critically appraise the overall educational value (OEV) of rotations. Successful rotations must satisfy Residency Review Committee mandates and optimize the service-to-education ratio (SER). This study was designed to examine the relationship between the OEV and SER and identify rotation characteristics (RC) associated with both.The Division of Surgery Education at the Hospital of the University of Pennsylvania administered a survey in FY2011 to all residents detailing resident perceptions regarding OEV, SER, and other RC. Responses were linked to additional rotation data. The relationship between OEV and SER was examined before and after controlling for significant RC identified in univariate analyses. Subgroup analyses by junior (CY1-2) and senior (CY3-5) resident status were performed.The survey was sent to 85 residents participating in 48 general surgery rotations, with an overall response rate of 87%. OEV was inversely proportional to SER. All RC were significant predictors of OEV in univariate models except rotation length, patient care participation and the presence of fellows. SER alone was a significant predictor of OEV (coefficient = -1.24, p0.001) and explained 68% of the variation in OEV. After including other RC, SER remained a significant predictor (coefficient = -1.08, p0.001) and the model explained 85% of the variation in OEV. In subgroup analysis, SER remained a significant predictor of OEV for junior residents (coefficient = -1.27, p =0.001), but not for senior residents (coefficient = -0.46, p = 0.15).The SER is inversely correlated with the OEV of general surgery rotations for the aggregate group of surgical residents, but this relationship appears to be attenuated by other factors in the senior resident group. Identification of the factors that affect junior surgical residents may provide the ability to improve the SER for junior residents and allow for significant improvements in perceived OEV for the resident body as a whole.

INTRODUCTION: The management of complex fistulas is difficult. Maintaining continence while achieving durable fistula closure is the goal of surgical management. This study describes our experience with a novel sphincter-sparing technique called the ligation of the intersphincteric fistula tract, which involves ligation and division of the fistula tract in the intersphincteric space. METHODS: All patients from July 2007 to December 2008 with trans- or suprasphincteric fistula treated with the procedure were prospectively followed. Procedures were performed by surgeons with fellowship training in a referral center. Demographic data, comorbidities, previous repair attempts, and postoperative data were collected. RESULTS: A total of 39 patients underwent a ligation of the intersphincteric fistula tract during a 17-month period. Median age was 49 years. A total of 29 patients (74%) had previous attempts at repair, with a median of 2 failed repairs. Follow-up data were available in 90% (35 of 39). Median follow-up was 20 weeks. Successful fistula closure was achieved in 57% of the patients (20 of 35). Median time to failure was 10 weeks (range, 2-38 weeks). No patient reported any subjective decrease in continence after the procedure. CONCLUSION: Ligation of the intersphincteric fistula tract is a new sphincter-sparing procedure for complex transsphincteric fistula. The success rate is comparable with other sphincter-preserving techniques. Importantly, it appeared to effectively preserve continence. Adding safe, muscle-sparing surgical options to our armamentarium for dealing with transsphincteric fistula is essential. Additionally, the procedure is easy to learn and has very low cost. Long-term follow-up and randomized, controlled trials are necessary to assess efficacy and durability.

To evaluate whether suction or water seal is superior in the management of chest tubes after pulmonary resection.A prospective, randomized, controlled trial. After an initial, brief period of suction, patients were randomized to water seal or - 20 cm H(2)O suction.University hospital.Sixty-eight patients who underwent wedge resection, segmentectomy, or lobectomy were included in the study. Those patients who underwent reoperative surgery or lung volume reduction surgery were excluded.There were 34 patients in each group. The two groups were evenly matched for age, sex, operation performed, severity of lung disease, and nutritional status. Fifteen patients in each group (44%) had an air leak at the completion of surgery. The duration of the air leak was shorter in the water seal group than in the suction group (mean +/- SEM, 1.50 +/- 0.32 days vs 3.27 +/- 0.80 days, respectively; p = 0.05). The mean times to removal of chest tubes were 3.33 +/- 0.35 days in the water seal group and 5.47 +/- 0.98 days in the suction group (p = 0.06). The length of stapled parenchyma was measured for each patient and averaged 24.9 cm for the water seal group and 18.5 cm for the suction group (p = 0.18). When corrected for the length of staple lines, the duration of air leaks and days with chest tube were dramatically lower in the water seal group (p = 0.02 and p = 0.02, respectively).Placing chest tubes on water seal after a brief period of suction after pulmonary resection shortens the duration of the air leak and likely decreases the time that the chest tubes remain in place. Adoption of this practice may result in lower morbidity and lower hospital costs.

Fistula-in-ano is a difficult problem that physicians have struggled with for centuries. Appropriate treatment is based on 3 central tenets: (1) control of sepsis; (2) closure of the fistula; and (3) maintenance of continence. Treatment options continue to evolve - as a result, it is important to review old and new options on a regular basis to ensure that our patients are provided with up to date information and options. This paper will briefly cover some of the traditional approaches that have been used as well as some newer promising procedures.