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BACKGROUND: Inflammatory bowel diseases (IBD) are chronic inflammatory affections of recurrent nature whose incidence and prevalence rates have increased, including in Brazil. In long term, they are responsible for structural damage that impacts quality of life, morbidity and mortality of patients. OBJECTIVE: To describe the profile of physicians who treat IBD patients as well as the characteristics of IBD care, unmet demands and difficulties. METHODS: A questionnaire containing 17 items was prepared and sent to 286 physicians from 101 Brazilian cities across 21 states and the Federal District, selected from the register of the State Commission of the “Study Group of Inflammatory Bowel Disease of Brazil” (GEDIIB). RESULTS: The majority of the physicians who answered the questionnaire were gastroenterologists and colorectal surgeons. More than 60% had up to 20 years of experience in the specialty and 53.14% worked at three or more locations. Difficulties in accessing or releasing medicines were evident in this questionnaire, as was referrals to allied healthy professionals working in IBD-related fields. More than 75% of physicians reported difficulties in performing double-balloon enteroscopy and capsule endoscopy, and 67.8% reported difficulties in measuring calprotectin. With regard to the number of patients seen by each physician, it was shown that patients do not concentrate under the responsibility of few doctors. Infliximab and adalimumab were the most commonly used biological medicines and there was a higher prescription of 5-ASA derivatives for ulcerative colitis than for Crohn’s disease. Steroids were prescribed to a smaller proportion of patients in both diseases. The topics “biological therapy failure” and “new drugs” were reported as those with higher priority for discussion in medical congresses. In relation to possible differences among the country’s regions, physicians from the North region reported greater difficulty in accessing complementary exams while those from the Northeast region indicated greater difficulty in accessing or releasing medicines. CONCLUSION: The data obtained through this study demonstrate the profile of specialized medical care in IBD and are a useful tool for the implementation of government policies and for the Brazilian society as a whole.

Rectal prolapse is relatively uncommon in male patients. The aim of this study was to compare males and females who underwent rectal prolapse surgery.Retrospective analysis of the ACS NSQIP public use file.Among 12,220 patients, 978 (8%) were male and 11,242 (92%) were female. Males were younger, 56 (38-73) vs. 71 (58-83) years, less often white (83% vs. 71%), had lower ASA scores, and underwent more laparoscopic (33% vs. 27%), more open (33% vs. 29%), and less perineal (33% vs 44%) procedures (all p 0.05). Morbidity (9.9% vs. 10.0%), reoperation (3.4% vs. 3.1%), and readmission (5.7% vs. 6.0%) were not different for males and females. In subgroup analysis by surgical procedure type, there remained no outcome differences. Propensity matched analysis revealed no difference in the use of laparoscopic, open, or perineal procedures.Males with rectal prolapse are younger, have a different racial distribution, a lower surgical risk profile, and undergo different surgical procedures than females, which appears to be driven by patient age and surgical risk assessment.

Gastrointestinal stromal tumors, although rare, are the most common primary mesenchymal neoplasms of the gastrointestinal tract and originate from the interstitial cells of Cajal. They present slow growth and symptoms such as bleeding, abdominal pain or discomfort, and the presence of an abdominal mass. The most affected organs are the stomach and small intestine. Differential diagnoses for gastrointestinal stromal tumor include adenocarcinoma and small intestine lymphoma, metastasis, and carcinoid tumor. Gastrointestinal stromal tumors have been associated with familial syndromes such as type 1 neurofibromatosis, considered a predisposing factor for tumors in the small intestine. This study aimed to report a case of gastrointestinal stromal tumor in the jejunal region in a patient with type 1 neurofibromatosis, followed-up for two years, who underwent laparoscopic segmental enterectomy and diagnosis determined by histopathology and immunohistochemistry. The diagnosis of small intestine gastrointestinal stromal tumor is challenging because of its low incidence, nonspecific symptoms, relative inaccessibility of the small intestine to conventional endoscopic examination, broad spectrum of radiological appearances, and the fact that the nature of the mass is difficult to determine with imaging examinations of the abdomen alone. Thus, the small intestine gastrointestinal stromal tumor may be erroneously diagnosed as pancreatic, gynecological, or mesenteric tumors. The literature does not present many reports on the association of jejunal gastrointestinal stromal tumor with neurofibromatosis. Understanding the tumoral behavior of small intestine gastrointestinal stromal tumor in this subgroup of patients would allow better follow-up. Resumo: Os tumores estromais gastrointestinais, embora raros, são as neoplasias mesenquimais primárias mais comuns do trato gastrointestinal e originam-se das células intersticiais de Cajal. Apresentam crescimento lento e manifestam sintomas como sangramento, dor ou desconforto abdominal e presença de massa abdominal. Os órgãos mais acometidos são estômago e intestino delgado. Os diagnósticos diferenciais para tumores estromais gastrointestinais incluem adenocarcinoma e linfoma de intestino delgado, metástases e tumor carcinoide. Os tumores estromais gastrointestinais têm sido associados a síndromes familiares como a neurofibromatose tipo 1, considerada um fator predisponente para tumores no intestino delgado. O objetivo desse trabalho é relatar um caso de tumor estromal gastrointestinal em região jejunal em paciente portadora de neurofibromatose tipo 1, com 2 anos de seguimento, submetida a enterectomia segmentar laparoscópica e diagnóstico determinados pela histopatologia e imuno-histoquímica. O diagnóstico de tumor estromal gastrointestinal do intestino delgado é desafiador, devido a sua baixa incidência, sintomas inespecíficos, relativa inacessibilidade do intestino delgado ao exame endoscópico convencional, amplo espectro de aparências radiológicas e difícil determinação da natureza da massa apenas com exames de imagens do abdome. Assim, tumor estromal gastrointestinal no intestino delgado podem ser erroneamente diagnosticados como tumores pancreáticos, tumores ginecológicos, ou tumores do mesentério. A descrição científica da associação de tumor estromal gastrointestinal de jejuno com neurofibromatose é incomum. Tais descrições permitem melhor seguimento dos pacientes a partir do momento que se entende o comportamento tumoral do tumor estromal gastrointestinal de intestino delgado nesse subgrupo de pacientes. Keywords: Gastrointestinal neoplasms, Gastrointestinal stromal tumors, Small intestine, Type 1 neurofibromatosis, Palavras-chave: Neoplasias gastrointestinais, Tumores do estroma gastrointestinal, Intestino delgado, Neurofibromatose tipo 1

Background The epidemiology of inflammatory bowel disease (IBD) in developing countries may uncover etiopathogenic factors. We investigated IBD prevalence in Brazil by investigating its geographic, spatial, and temporal distribution, and attempted to identify factors associated with its recent increase. Methods A drug prescription database was queried longitudinally to identify patients and verify population distribution and density, race, urbanicity, sanitation, and Human Development Index. Prevalence was calculated using the number of IBD patients and the population estimated during the same decade. Data were matched to indices using linear regression analyses. Results We identified 162 894 IBD patients, 59% with ulcerative colitis (UC) and 41% with Crohn’s disease (CD). The overall prevalence of IBD was 80 per 100 000, with 46 per 100 000 for UC and 36 per 100 000 for CD. Estimated rates adjusted to total population showed that IBD more than triplicated from 2008 to 2017. The distribution of IBD demonstrated a South-to-North gradient that generally followed population apportionment. However, marked regional differences and disease clusters were identified that did not fit with conventionally accepted IBD epidemiological associations, revealing that the rise of IBD was variable. In some areas, loss of biodiversity was associated with high IBD prevalence. Conclusions When distribution is considered in the context of IBD prevalence, marked regional differences become evident. Despite a background of Westernization, hotspots of IBD are recognized that are not explained by population density, urbanicity, sanitation, or other indices but apparently are explained by biodiversity loss. Thus, the rise of IBD in developing countries is not uniform, but rather is one that varies depending on yet unexplored factors like geoecological conditions.

Crohn's disease is a chronic, inflammatory bowel condition that can affect the entire digestive tract and in many cases lead to enteric fistula formation. The management of enteric fistulas can be challenging and often requires a multidisciplinary approach.

Cholelithiasis (ChL) is common after bariatric surgery (BS). Laparoscopic cholecystectomy (LC), the preferential treatment, is usually recommended only to symptomatic patients. LC may be, however, beneficial to asymptomatic patients as well. A prerequisite to such a policy is that it must be safe. This study aimed to assess whether, in post-bariatric (Post-Bar) patients who develop gallstones, LC achieves the same results as those reported in the general population. A cohort of 376 patients undergoing elective LC had their medical records reviewed. Patients were divided into non-bariatric (Non-Bar) and Post-Bar groups, and then compared for characteristics and surgical outcomes. The study included 367 patients, 292 Non-Bar and 75 Post-Bar. Considering characteristics, Post-Bar patients were younger (44.5 ± 11.8 vs 48.4 ± 14.1) and less symptomatic (2.4% vs 19.8%) and had a higher BMI (32.2 ± 4.8 vs 30.8 ± 4.4) than Non-Bar patients. Regarding surgical outcomes, mortality (none), morbidity (1%, only in Non-Bar patients), readmission (1%, only in Non-Bar patients), conversion to laparotomy (0.6%, only in Non-Bar patients) showed no difference between the groups. Operative time (42.6 ± 14.4 min in Non-Bar and 38.2 ± 12.6 min in Post-Bar patients) tended to be lower in Post-Bar patients, p = 0.054. Same-day discharge was higher in Post-Bar patients (98.6%) than in Non-Bar patients (90.4%), p = 0.03. Compared with Non-Bar patients, LC in Post-Bar patients showed not only similar morbimortality, readmissions, and conversions but also even a higher same-day discharge rate and a trend to lower operative times.

Neoadjuvant chemoradiation (CRT) has been established as standard treatment for stage II and III rectal cancer, and delayed interval between CRT and rectal resection has emerged as appropriate treatment due to the marked benefits associated with this approach. Despite favorable findings on downstaging and pathological complete response without increasing in morbidity and mortality, no significant improvement in sphincter preservation rate and rectal cancer overall survival has been observed with the current recommended 6–8-week interval. Trials are currently underway and may provide answers regarding the optimal interval between CRT and surgical resection, but until now, the best interval between CRT and surgery remains unclear.

Abdominal perineal excision (APE) has been associated with a high risk of positive circumferential resection margin (CRM+) and local recurrence rates in the treatment of rectal cancer. An alternative extralevator approach (ELAPE) has been suggested to improve the quality of resection by avoiding coning of the specimen decreasing the risk of tumor perforation and CRM+. The aim of this study is to compare the quality of the resected specimen and postoperative complication rates between ELAPE and “standard” APE. All patients between 1998 and 2014 undergoing abdominal perineal excision for primary or recurrent rectal cancer at a single Institution were reviewed. Between 1998 and 2008, all patients underwent standard APE. In 2009 ELAPE was introduced at our Institution and all patients requiring APE underwent this alternative procedure (ELAPE). The groups were compared according to pathological characteristics, specimen quality (CRM status, perforation and failure to provide the rectum and anus in a single specimen—fragmentation) and postoperative morbidity. Fifty patients underwent standard APEs, while 22 underwent ELAPE. There were no differences in CRM+ (10.6 vs. 13.6%; p = 0.70) or tumor perforation rates (8 vs. 0%; p = 0.30) between APE and ELAPE. However, ELAPE were less likely to result in a fragmented specimen (42 vs. 4%; p = 0.002). Advanced pT-stage was also a risk factor for specimen fragmentation (p = 0.03). There were no differences in severe (Grade 3/4) postoperative morbidity (13 vs. 10%; p = 0.5). Perineal wound dehiscences were less frequent among ELAPE (52 vs 13%; p

Purpose: the aim of this study was to identify the risk factors for readmission among patients submitted to colorectal surgery. Methods: a single-center colorectal quality-assessment database was queried for patients undergoing colorectal procedures with ileostomy during 2009. the sample was divided into readmitted vs. non-readmitted. readmission was defined as admission within the first 30 days after the index procedure. Groups were compared by pre, intra and postoperative characteristics. A multivariate analysis was performed to identify the risk factors for readmission. Results: the query returned 496 patients, [267 (54%) males, median age 48 years (iQr: 34-60)]. Eighty-three (17%) were readmitted; 296 patients (60%), were operated due to inflammatory bowel disease, 89 (18%) for cancer, 16 (3%) for diverticular disease and 95 (19%) for other diagnosis. the three most common procedures were total proctocolectomy with ileal pouch-anal anastomosis (iPAA) in 103 patients (21%), total colectomy with end ileostomy in 117 (24%) and small bowel resections (including enterocutaneous fistula takedown and J-pouch excision) in 149 (30%). the following variables were significantly more common in readmitted patients: current smoking (24% vs. 14%, p = 0.02), postoperative DVt/PE (10% vs. 4%, p = 0.04), wound infection (20% vs. 10% p = 0.01), sepsis (22% vs. 8% p < 0.001) and organ or space surgical site infection (orgSSi) (35% vs. 5%, p < 0.001). Postoperative orgSSi was the only independent factor associated with readmission in a multivariate analysis (p < 0.001). Conclusion: colorectal surgeons should be alert for orgSSi when facing an ileostomy patient readmitted after a colorectal procedure. Resumo: Objetivo: o objetivo deste estudo foi identificar os fatores de risco para readmissão em pacientes submetidos à cirurgia colorretal. Métodos: um banco de dados de avaliação da qualidade colorretal em um único centro foi consultado para pacientes submetidos à procedimentos colorretais com ileostomia em 2009. A amostra foi dividida em readmitidos versus não readmitidos. A readmissão foi definida como a admissão dentro dos primeiros 30 dias após o procedimento índice. os grupos foram comparados em relação à características pré, intra e pós-operatórias. A análise multivariada foi realizada para identificar os fatores de risco para readmissão. Resultados: a consulta identificou 496 pacientes, [267 (54%) do sexo masculino, idade média de 48 anos (ViQ: 34 -60)]. oitenta e três (17%) foram readmitidos; 296 pacientes (60%) foram operados por doença inflamatória intestinal, 89 (18%) por câncer, 16 (3%) por doença diverticular e 95 (19%) devido a outro diagnóstico. os três procedimentos mais comuns foram proctocolectomia total com anastomose anal e bolsa ileal (iPAA) em 103 pacientes (21%), colectomia total com ileostomia final em 117 (24%) e ressecções do intestino delgado (incluindo a remoção de fístula enterocutânea e excisão da bolsa em J) em 149 (30%). As seguintes variáveis foram significativamente mais comuns em pacientes readmitidos: tabagismo atual (24% vs. 14%, p = 0,02), tVP/EP pós-operatório (10% vs. 4%, p = 0,04), infecção da ferida cirúrgica (20% vs. 10% p = 0,01), sepse (22% vs. 8%, p < 0,001) e infecção de órgão/espaço do sítio cirúrgico (ioSC) (35% vs. 5%, p < 0,001). A infecção do ioSC pós-operatório foi o único fator independente associado com a readmissão na análise multivariada (p < 0,001). Conclusão: os cirurgiões colorretais devem estar alertas para ioSC diante de um paciente com ileostomia readmitido após um procedimento colorretal. Keywords: ileostomy readmission, Palavras-chave: ileostomia readmissão

A minimum of 12 examined lymph nodes (LN) is recommended to ensure adequate staging and oncologic resection of patients undergoing proctectomy for rectal adenocarcinoma. However, a decreased number of LN is not unusual in patients receiving neoadjuvant chemoradiation.We hypothesized that a decreased number of LN in the proctectomy specimen of these patients may be an indicator of tumor response and be associated with improved prognosis.A single-center colorectal cancer database was queried for c-stage II-III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized into two groups according to the number of LN retrieved from the proctectomy specimen:12 LN versus ≥12 LN. Groups were compared with respect to demographics, tumor and treatment characteristics, and the following oncologic outcomes: overall-survival (OS), cancer-specific-mortality (CSM), cancer-free-survival (CFS), distant (DR), and local recurrences (LR).The query returned 237 patients. There were 173 (73 %) males, and the median age was 57 years [interquartile range (IQR) 49-66 years]. The median number of LN retrieved was 15 (IQR 10-23) and 70 (30 %) patients had less than 12 nodes examined. The12 nodes group was older [60 (IQR 51-71 years) vs. 55 (IQR 48-65 years), p = 0.009] and had more pathologic complete responders (36 vs. 19 %, p = 0.01). No12 nodes patient experienced a LR, whereas the 5-year LR rate was 11 % in the ≥12 nodes group (p = 0.004). Other oncologic outcomes were not significantly different.Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.

PURPOSE: To investigate the correlation between bursting pressure and breaking strength on the 7th postoperative day following left colonic anastomosis in rats. METHODS: Seventy rats were randomly divided into seven groups of ten animals each. All of the animals underwent segmental resection of the left colon and end-to-end anastomosis. The animals in groups I to VI underwent surgical laparoscopies with pneumoperitoneums using carbon dioxide or helium at pressures of 5, 12 or 20 mmHg. In Group VII, open laparotomy was performed. The animals were reoperated on postoperative day 7 to measure the bursting pressure and the breaking strength of the anastomosis. RESULTS: The anastomosis bursting pressure in 70 animals was 193.10±55.56 mmHg. There was no significant difference between the groups (p=0.786). The breaking strength of the anastomosis was 0.26±0.12 N. There was no significant difference between the groups (p=0.356). Pearson's correlation test showed a low correlation (r=0.231) lacking statistical significance (p=0.054). CONCLUSION: There was no correlation between the bursting pressure and breaking strength of left colonic anastomoses in rats on the 7th postoperative day.

Objective: Laparoscopic approach should be offered for most patients requiring colectomy, as it is a safe procedure, associated with shorter hospitalization, better cosmetic results, and does not affect negatively the oncological outcomes of patients with colon cancer. However, there is no consistent data on the safety of laparoscopic surgery training during residency. Therefore, the aim of this study was to assess whether or not the resident par- ticipation in laparoscopic colectomy affected the postoperative outcomes. Methods: The database of the American College of Surgeons National Surgical Quality Im- provement Program (ACS-NSQIP) was searched for patients undergoing laparoscopic col- ectomies between 2005 and 2007. We excluded patients with no data regarding whether or not there was a resident participation in the operation. The study population was divided into 2 groups (resident and nonresident), according to residents participation in the surgi- cal procedure. Perioperative variables and postoperative complications were compared be- tween groups. A multivariate analysis was performed to evaluate the association between postoperative complications and resident participation in the operation. Results: The search yielded 5,912 patients with a median age of 63 years. Of these, 3,112 (53%) were female and 3.887 (66%) had a resident involved in their operation. The resident group had a significantly longer mean operative time (163 ± 64 min vs 138 ± 58 min, p < 0.0001). Other variables did not differ significantly between groups. Moreover, multivari- ate analysis showed no association between resident participation and the occurrence of postoperative complications. Conclusion: Laparoscopic training during residency may be safely performed without threatening the patient's integrity. Resumo: Objetivo: Cirurgia videolaparoscópica é a via preferencial para colectomias eletivas por ser um procedimento seguro, associado à menor tempo de internação, melhores resultados estéticos e por não influenciar negativamente os resultados oncológicos dos pacientes com câncer de cólon. Entretanto, ainda não existem dados consistentes sobre a segurança do treinamento em cirurgia laparoscópica durante a residência. Sendo assim, o objetivo deste estudo foi avaliar se a participação do residente em colectomias laparoscópicas afetou os resultados pós-operatórios. Métodos: A base de dados do American College of Surgeons National Surgical Quality Im- provement Program (ACS-NSQIP) foi pesquisada para colectomias laparoscópicas entre os anos de 2005 e 2007. A população do estudo foi dividida em dois grupos de acordo com a participação ou não do residente na cirurgia: residente vs. não residente. Os grupos foram comparados em relação às variáveis perioperatórias e complicações pós-operatórias. Uma análise multivariada foi realizada para investigar possível associação entre complicações pós-operatórias e o envolvimento de residentes na operação. Resultados: A pesquisa retornou 5.912 pacientes, com mediana de idade de 63 anos. Em 3.887 casos (66%) o residente estava envolvido na operação. O grupo Residente apresentou tempo operatório mediano significantemente maior que o grupo Não Residente (163 ± 64 min vs. 138 ± 58 min, p < 0.0001). Todas as outras variáveis estudadas não diferiram signifi- cativamente entre os grupos. Além disso, a análise multivariada não demonstrou nenhuma associação entre o envolvimento do residente na operação e a ocorrência de complicações pós-operatórias. Conclusão: O treinamento laparoscópico durante a residência pode ser realizado com segu- rança sem colocar em risco a integridade do paciente operado. Keywords: Videolaparoscopy, Colectomy, Palavras-chave: Videolaparoscopia, Colectomia

The purpose of this study was to evaluate the 30-day postoperative complications rate in patients undergoing elective total abdominal colectomy (TAC) for chronic constipation, neoplastic disorders, and inflammatory bowel disease (IBD) using the American College of Surgeons National Quality Improvement Database (ACS-NSQIP). The 2007 ACS-NSQIP sample was used to identify the Current Procedural Terminology codes for TAC and International Classification of Diseases, 9th Revision codes for chronic constipation, neoplasia, and IBD. Preoperative and intraoperative variables and postoperative complications were compared among the three diagnosis groups. Wilcoxon rank sum and Fisher exact tests were used for analysis. P < 0.05 was considered significant. Seven hundred forty-four patients were identified; chronic constipation was found in 107 (14.4%) patients, neoplasia in 312 (42.3%), and IBD in 322 (43.3%). Patients with constipation were predominantly females (85.2%). The neoplastic group was older and had greater body mass index when compared with the other groups. Patients with IBD presented greater use of steroids, lower albumin and hematocrit levels, and higher morbidity probability. Constipated patients had more neurologic and renal complications when compared with the IBD group ( P = 0.01). None of the other categories of complications were statistically different among the diagnosis groups. With the exception of urinary tract infection being higher in the constipation patients compared with IBD (10 vs 4%, P = 0.03), there were no statistically significant differences among the other short-term specific complications. The 30-day complication rate after TAC is similar for chronic constipation, neoplasia, and IBD.

BACKGROUND There is debate whether performing the perineal part of the abdominoperineal resection in a prone position in comparison with a lithotomy position optimizes circumferential resection margins and, subsequently, cancer outcomes. OBJECTIVE The aim of this study was to compare outcomes of patients undergoing abdominoperineal in a prone vs a lithotomy position. DESIGN A single-center, prospectively maintained colorectal cancer database was queried for patients with stages I to III rectal cancer undergoing abdominoperineal resection in a prone vs a lithotomy position from 1997 to 2007. Patients were compared with respect to demographics, tumor and treatment characteristics, perioperative morbidity, and oncologic outcomes. Oncologic outcomes were adjusted for age, ASA class, tumor stage, and use of adjuvant treatments. χ², Fisher exact probability test, Wilcoxon rank-sum test, Kaplan-Meier estimates, log-rank sum test, and Cox regression models were used for the analysis. P < .05 was considered significant. RESULTS The query returned 168 patients (81 prone and 87 lithotomy), with a median age of 63 (interquartile range, 52-74) years and a median follow-up of 42 (interquartile range, 23-69) months. Prone and lithotomy patients were not statistically different regarding demographics, tumor stage, rates of R0 resection, number of harvested nodes, perioperative morbidity, follow-up time, and oncologic outcomes. CONCLUSIONS Surgical positioning during the perineal part of the abdominoperineal resection does not affect perioperative morbidity or oncologic outcomes and should be left to the surgeon's discretion.

The benefits of laparoscopic (LC) over open colectomy (OC) have been well characterized for a variety of conditions. Whether the relative benefits of LC differ for different conditions has not been previously investigated. The aim of this study was to identify whether there are differences in benefits of LC for colon cancer (CC), Crohn's disease (CD), and diverticular disease (DD). Data of patients with CC, CD, and DD undergoing elective colectomy from January 2000 to December 2007 were identified from departmental databases. Patients with CC, CD, and DD undergoing LC were matched 1:1 for diagnosis, gender, body mass index, surgical procedure, American Society of Anesthesiologists scale, and date of surgery to patients undergoing OC. TNM stage was also matched for patients with CC. Two hundred eighty-nine patients undergoing LC (CC, 93; CD, 140; DD, 56) were matched 1:1 to 289 patients undergoing OC. Median age was 49 years (range, 14 to 91 years) in LC and 52 years (range, 14 to 98 years) in OC ( P = 0.35). All other matched criteria were also similar in both groups. The conversion rate to OC was 13 per cent (n = 36). Patients undergoing LC had significantly shorter lengths of stay (LOS) (3 days [range, 1 to 70 days] vs 6 days [range, 1 to 37 days], P < 0.001) and lower estimated blood loss (EBL) (100 mL [range, 10 to 1750 mL] vs 200 mL [range, 10 to 1700 mL], P < 0.001). Median operative time was similar in both groups (LC: 145 minutes [range, 35 to 431 minutes] vs OC: 135 minutes [range, 23 to 485 minutes], P = 0.54). The conversion rate was lower for DD (2%) when compared with CC (18.9%) and CD (13.4%). Improvement in EBL with LC was least pronounced in patients with CD and most pronounced in patients with DD ( P interaction < 0.001). In the LC group, patients with DD presented less postoperative complications ( P = 0.009). LC results in reduced LOS and EBL with similar complications rates when compared with OC. The benefits of LC are more pronounced in DD when compared with CD and CC.

The aim of this study was to determine the effect of a longer interval between neoadjuvant chemoradiation and surgery on perioperative morbidity and oncologic outcomes. A colorectal cancer database was queried for clinical stage II and III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. The neoadjuvant regimen consisted of long course external beam radiation and 5-fluorouracil chemotherapy. Patients with inflammatory bowel disease, hereditary cancer, extracolonic malignancy, urgent surgery, or non-validated treatment dates were excluded. Patients were divided into two groups according to the interval between chemoradiation and surgery (

The aim of this study was to evaluate whether downstaging impacts prognosis in patients with cII versus cIII rectal cancer. We identified from our colorectal cancer database 295 patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI who received 5-FU-based chemoradiation followed by R0 surgery after a median interval of 7 weeks during 1997–2007. The median radiotherapy dose was 5040 cGy. We excluded 58 patients with pathologic complete response (pCR) and compared among the remaining 162 patients pathologic downstaging (cII to ypI, cIII to ypII or ypI) versus no pathologic downstaging (c stage ≤ yp stage). Outcomes evaluated were 5-year overall survival, 3-year cancer-specific survival, disease-free survival, overall recurrence, local recurrence, and distant recurrence. The median age was 58 years and median follow-up was 48 months. Patients with downstaging versus no downstaging were statistically comparable with respect to demographics, chemoradiation regimen, interval time between neoadjuvant chemoradiation and surgery, tumor distance from anal verge, surgical procedures performed, and follow-up time. With the exception of local recurrence rates, downstaging resulted in significantly improved cancer outcomes for cIII but not cII. Downstaging without pCR is a significant prognostic factor for patients with stage cIII rectal cancer. Tumor response to neoadjuvant chemoradiation should be taken into account when defining the optimal adjuvant chemotherapy regimen for patients with cIII rectal cancer.

This study evaluates factors associated with a pathologic complete response (pCR) after neoadjuvant chemoradiation for rectal cancer.Approximately 20% of rectal cancer patients undergoing neoadjuvant chemoradiation achieve pCR, which has been associated with decreased local recurrence and improved recurrence-free survival. Means of predicting pCR remain incompletely defined.A total of 306 consecutive patients with stage II or stage III rectal cancer who underwent neoadjuvant chemoradiation then surgery between 1997 and 2007 were identified from a single-institution. Sixty-four patients with concurrent inflammatory bowel disease, hereditary colorectal cancer, other malignancy, urgent surgery, incomplete chemoradiation, or insufficient data were excluded. All patients received neoadjuvant 5-FU-based chemotherapy and external beam radiation. Histologic response was categorized as pCR or not-pCR, which defined the 2 study cohorts. Variables were analyzed by univariate and multivariate analysis with pCR as the dependent variable. Fisher exact test, chi2, Wilcoxon rank-sum, and logistic regression were used for analysis. P0.05 was considered statistically significant.Of the total patients, 242 were studied, including 58 (24%) that achieved pCR. The 2 groups were statistically similar in terms of age, gender, body mass index, tumor differentiation, radiation dose, and pretreatment stage. On multivariate analysis, an interval ≥ 8 weeks between treatment completion and surgical resection was significantly associated with a higher rate of pCR, which correlated with decreased local recurrence and improved overall survival.Despite traditional beliefs that certain patient and tumor factors influence pCR, an extended interval between completion of neoadjuvant therapy and surgery was the single most important determinant in achieving a pCR.

Objective: Colorectal surgeons often struggle to explain to administrators/payers reasons for prolonged length of stay (LOS). This study aim was to identify factors associated with increased LOS after colorectal surgery. Design: The study population included patients from the 2007 American-College-of-Sur- geons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database undergoing ileocolic resection, segmental colectomy, or anterior resection. The study population was divided into normal (below 75th percentile) and prolonged LOS (above the 75th percentile). A multivariate analysis was performed using prolonged LOS as dependent variable and ACS- NSQIP variables as predictive variables. P-value < 0.01 was considered significant. Results: 12,269 patients with a median LOS of 6 (inter-quartile range 4-9) days were includ- ed. There were 2,617 (21.3%) patients with prolonged LOS (median 15 days, inter-quartile range 13-22). 1,308 (50%) were female, and the median age was 69 (inter-quartile range 57-79) years. Risk factors for prolonged LOS were male gender, congestive heart failure, weight loss, Crohn's disease, preoperative albumin < 3.5 g/dL and hematocrit < 47%, base- line sepsis, ASA class ≥ 3, open surgery, surgical time ≥ 190 min, postoperative pneumonia, failure to wean from mechanical ventilation, deep venous thrombosis, urinary-tract in- fection, systemic sepsis, surgical site infection and reoperation within 30-days from the primary surgery. Conclusion: Multiple factors are associated with increased LOS after colorectal surgery. Our results are useful for surgeons to explain prolonged LOS to administrators/payers who are critical of this metric. Resumo: Objetivo: Os cirurgiões proctologistas muitas vezes enfrentam dificuldades para explicar aos administradores/contribuintes as razões para o prolongamento do tempo de interna- ção hospitalar (TIH). O objetivo deste estudo foi identificar os fatores associados ao aumen- to do TIH após cirurgia colorretal. Método: A população do estudo incluiu pacientes que constam do banco de dados do Ame- rican College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) no ano de 2007 e que foram submetidos à ressecção ileocólica, colectomia segmentar ou res- secção anterior. A população do estudo foi dividida em normal (abaixo do percentil 75) e TIH prolongado (acima do percentil 75). A análise multivariada foi realizada usando o TIH prolongado como variável dependente e as variáveis do ACS-NSQIP como preditivas. Um valor de p < 0,01 foi considerado significativo. Resultados: No total, 12.269 pacientes com um TIH mediano de 6 dias (intervalo interquartil, 4-9) foram incluídos. Havia 2.617 pacientes (21,3%) com TIH prolongado (mediana, 15 dias; in- tervalo interquartil, 13-22). A idade média dos pacientes era de 69 anos (intervalo interquartil, 57-79) e 1.308 (50%) eram do sexo feminino. Os fatores de risco para TIH prolongado foram sexo masculino, insuficiência cardíaca congestiva, perda de peso, doença de Crohn, albu- mina < 3,5 g/dL e hematócrito < 47% no pré-operatório, sepse basal, classe ASA ≥ 3, cirurgia aberta, tempo cirúrgico ≥ 190 minutos, pneumonia no pós-operatório, falha no desmame da ventilação mecânica, trombose venosa profunda, infecção do trato urinário, sepse sistêmica, infecção do sítio cirúrgico e reoperação dentro de 30 dias da cirurgia primária. Conclusão: Vários fatores estão associados ao aumento do TIH após a cirurgia colorretal. Nossos resultados são úteis para que os cirurgiões possam explicar os TIH prolongados aos administradores/contribuintes que são críticos dessa métrica. Keywords: Colectomy, Morbidity, Length of stay, Palavras-chave: Colectomia, Morbidade, Tempo de internação

Enterocutaneous fistula (ECF) associated with cancer or radiation injury increases the complexity of normal management. Factors such as timing of additional adjuvant therapy or palliative care, technical considerations for operating on irradiated bowel, poor wound healing, increased risk of additional ECF, and decreased likelihood of spontaneous ECF closure all need to be considered in this scenario. Here the authors focus specifically on the management of ECF associated with cancer and/or radiation-induced injury to the bowel.

PURPOSE: Issues related to body image and a permanent stoma after abdominoperineal resection may decrease quality of life in rectal cancer patients. However, specific problems associated with a low anastomosis may similarly affect quality of life for patients undergoing low anterior resection. The aim of this study was to compare quality of life of low rectal cancer patients after undergoing abdominoperineal resection versus low anterior resection. METHODS: Demographics, tumor and treatment characteristics, and prospectively collected preoperative quality-of-life data for patients undergoing low anterior resection or abdominoperineal resection for low rectal cancer between 1995 and 2009 were compared. Quality of life collected at specific time intervals was compared for the two groups, adjusting for age, body mass index, use of chemoradiation, and 30 days postoperative complications. The short-form-36 questionnaire was used to determine quality of life. RESULTS: The query returned 153 patients (abdominoperineal resection = 68, low anterior resection = 85) with a median follow-up of 24 (3-64) mo. The after abdominoperineal resection group had a higher mean age (63 ± 12 vs. 54 ± 12, p < 0.001) and more American Society of Anesthesiologists classification 3/4 patients (65 percent vs. 43 percent, p = 0.03) than low anterior resection. Other demographics, tumor stage, use of chemoradiation, overall postoperative complication rates, and quality-of-life follow-up time were not statistically different in both groups. Patients undergoing abdominoperineal resection had a lower baseline short-form-36 mental component score than those undergoing low anterior resection. However, 6 mo after surgery this difference was no longer statistically significant and essentially disappeared at 36 mo after surgery. CONCLUSION: Patients undergoing abdominoperineal resection for low rectal cancer have a similar long-term quality of life as those undergoing low anterior resection. These findings can help clinicians to better counsel patients with low rectal cancer who are being considered for abdominoperineal resection.

Background There is sufficient evidence to support the use of hand-assisted laparoscopy for sigmoid, total, and proctocolectomy. As a result, the hand-assisted technique has gained acceptance for these relatively complex types of colorectal surgery. For right colectomy, the use of conventional laparoscopy is supported by studies that have demonstrated its advantages over open surgery. Although the hand-assisted technique is also being used by some surgeons for right colectomy, there are few reported data to justify its use. With this deficiency in mind, we performed a study to compare the short-term outcomes of right colectomy performed by either the hand-assisted or conventional laparoscopic technique. Study Design A single-center retrospective analysis was performed. Patients who underwent hand-assisted or conventional laparoscopic right colectomy were identified from a prospectively maintained departmental database. Preoperative clinical information, details of the operation, lymph node count for cancer cases, postoperative morbidity, length of stay, and 30-day hospital readmissions were evaluated. Results From 2006 to 2009, 43 hand-assisted and 84 conventional laparoscopic right colectomies were performed. Comparison of the hand-assisted and conventional laparoscopic groups revealed no differences in the preoperative clinical variables, including average body mass index (calculated as kg/m 2 ; 28 and 29), percent obese (33% and 34%), earlier abdominal surgery (30% and 39%), operative time (122 and 126 minutes), lymph nodes evaluated for cancer cases (22 and 21), postoperative morbidity (30%), length of stay (5 days), or 30-day hospital readmission (16% and 11%). Conclusions Short-term outcomes of hand-assisted and conventional laparoscopic right colectomy are similar. The decision to perform hand-assisted or conventional laparoscopic right colectomy should be based on the surgeons' preference and not on the perception that one technique is preferable to the other.

The aim of this study was to evaluate the clinical implications of pathologic complete response (pCR) (i.e., T0N0M0) after neoadjuvant chemoradiation and radical surgery in patients with locally advanced rectal cancer.A single-center, prospectively maintained colorectal cancer database was queried for patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI undergoing long-course neoadjuvant chemoradiation followed by proctectomy with curative intent between 1997 and 2007. Patients were stratified into pCR and no-pCR groups and compared with respect to demographics, tumor and treatment characteristics, and oncologic outcomes. Outcomes evaluated were 5-year overall survival, disease-free survival, disease-specific mortality, local recurrence, and distant recurrence.The query returned 238 patients (73% male), with a median age of 57 years and median follow-up of 54 months. Of these, 58 patients achieved pCR. Patients with pCR vs no-pCR were statistically comparable with respect to demographics, chemoradiation regimens, tumor distance from anal verge, clinical stage, surgical procedures performed, and follow-up time. No patient with pCR had local recurrence. Overall survival and distant recurrence were also significantly improved for patients achieving pCR.Achievement of pCR after neoadjuvant chemoradiation is associated with greatly improved cancer outcomes in locally advanced rectal cancer. Future studies should evaluate the relationship between increases in pCR rates and improvements in cancer outcomes in this population.

The surgical oncologist's ability to identify which patients with stage II colon cancer should be referred to a medical oncologist is subjective and qualitative. It includes assessment of the qualitative aspects of the pathology reports, the patient's suitability to receive potentially toxic medication, and their personal preference. The prognosis of colorectal cancer varies greatly in accordance with disease stage and tumor site. Patients with stage II colon cancer are cured with surgery alone in 75% to 80% of cases. This means that if all patients with stage II tumors are referred to a medical oncologist, a large number will receive treatment that is not necessary and potentially toxic. If none are referred, some will be undertreated. The question is how to identify those who should appropriately be considered for adjuvant therapy. In this article, we will discuss the strengths and limitations of the factors that must be considered when making the decision to refer to a medical oncologist or not.