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Background Perineal hernias can be secondarily acquired following abdominoperineal resection of the rectum. While transabdominal minimally invasive techniques have traditionally used laparoscopy, there are few studies published on the robotic platform, which has been gaining popularity for other types of hernia repairs. We review the existing literature, share a video vignette, and provide practical tips for surgeons interested in adopting this approach. Methods A literature search in Pubmed was performed to include all articles in English describing robotic repair of perineal hernias with identification of variables of interest related to repair. A case presentation with an accompanying video vignette and lessons learned from the experience are provided. Results Seven case reports (four containing video) published between 2019 and 2022 were included. Most articles (n = 5) utilized the Da Vinci Si or Xi, and most patients (n = 5) had undergone abdominoperineal resection with neoadjuvant chemotherapy to treat rectal cancer. Patients were positioned in Trendelenburg with rightward tilt (n = 2), modified lithotomy (n = 1), or a combination of the two (n = 1). All articles (n = 7) reported closing the defect and using mesh. Three articles describe placing five ports (one camera, three robotic, one assistant). There were no significant intraoperative or postoperative complications reported, and no recurrence noted at 3–27 months follow-up. Based on our experience, as shown in the video vignette, we recommend lithotomy positioning, using porous polypropylene mesh anchored to the periosteum of the sacrum and peritoneum overlying the bladder and side wall, and placing a drain above the mesh. Conclusions A robotic transabdominal approach to perineal hernia repair is a viable alternate to laparoscopy based on low complication rates and lack of recurrence. Prospective and longer duration data are needed to compare the techniques.

PURPOSE Prospective data on the efficacy of a watch-and-wait strategy to achieve organ preservation in patients with locally advanced rectal cancer treated with total neoadjuvant therapy are limited. METHODS In this prospective, randomized phase II trial, we assessed the outcomes of 324 patients with stage II or III rectal adenocarcinoma treated with induction chemotherapy followed by chemoradiotherapy (INCT-CRT) or chemoradiotherapy followed by consolidation chemotherapy (CRT-CNCT) and either total mesorectal excision (TME) or watch-and-wait on the basis of tumor response. Patients in both groups received 4 months of infusional fluorouracil-leucovorin-oxaliplatin or capecitabine-oxaliplatin and 5,000 to 5,600 cGy of radiation combined with either continuous infusion fluorouracil or capecitabine during radiotherapy. The trial was designed as two stand-alone studies with disease-free survival (DFS) as the primary end point for both groups, with a comparison to a null hypothesis on the basis of historical data. The secondary end point was TME-free survival. RESULTS Median follow-up was 3 years. Three-year DFS was 76% (95% CI, 69 to 84) for the INCT-CRT group and 76% (95% CI, 69 to 83) for the CRT-CNCT group, in line with the 3-year DFS rate (75%) observed historically. Three-year TME-free survival was 41% (95% CI, 33 to 50) in the INCT-CRT group and 53% (95% CI, 45 to 62) in the CRT-CNCT group. No differences were found between groups in local recurrence-free survival, distant metastasis-free survival, or overall survival. Patients who underwent TME after restaging and patients who underwent TME after regrowth had similar DFS rates. CONCLUSION Organ preservation is achievable in half of the patients with rectal cancer treated with total neoadjuvant therapy, without an apparent detriment in survival, compared with historical controls treated with chemoradiotherapy, TME, and postoperative chemotherapy.

Background Preventing post-operative ileus (POI) is important given its associated morbidity and increased cost of care. The authors’ prior work showed that POI in patients with newly created ileostomies is associated with a post-operative day (POD) 2 net fluid balance of > + 800 mL. The purpose of this study was to conduct an initial assessment of the efficacy of a pilot intervention. Methods This is a single-institution, pre–post-intervention, proof-of-concept study conducted on the Colorectal Surgery service at the University of California, San Francisco. The study included 58 procedures with ileostomy formation by board-certified colorectal surgeons between August 13, 2020 and June 1, 2021. The intervention included three adjustments to the standard Enhanced Recovery After Surgery protocol: addition of diuresis, delay in advancement to solid food, and earlier stoma intubation. Demographics, intraoperative factors, post-operative fluid balance, and outcomes (POI, post-procedure length of stay [LOS], hospitalization cost, and re-admissions) were compared between patients pre- and post-intervention. Results Eight (13.8%) of the 58 procedures in the intervention period were associated with POI vs. a baseline POI rate of 32.6% (p = 0.004). Compared to patients without intervention, those with intervention had 67% less odds of POI (OR 0.33, 95% CI 0.15–0.73, p = 0.01). This difference remained significant when adjusted for age, gender, body mass index, procedure duration, and operative approach (adjusted OR 0.32, 95% CI 0.14–0.72, p = 0.01). Average POD2 stoma output was 0.3 L greater (1.1 L vs. 0.8L; p < 0.001) and net fluid balance was 1.8 L lower (+ 0.3 L vs. + 2.1 L; p < 0.00001) for these 58 cases. Average post-procedure LOS was 1.9 days lower (5.3 vs. 7.2 days, p < 0.001) and direct cost was $5561 lower ($21,652 vs. $27,213, p = 0.004), with no difference in 30-day readmissions (p = 0.43). Conclusions This pilot intervention shows promise for reduction in POI in patients with newly created ileostomies. Additional assessment is needed to confirm these initial findings.

Abstract Purpose We sought to determine whether adherence to the American Cancer Society (ACS) Nutrition and Physical Activity Guidelines was associated with better bowel function among colon cancer survivors. Methods This prospective cohort study included patients surgically treated for stage I–IV colon cancer enrolled in the Lifestyle and Outcomes after Gastrointestinal Cancer (LOGIC) study between February 2017 and May 2021. Participants were assigned an ACS score (0–6 points) at enrollment. Stool frequency (SF) was assessed every 6 months using the EORTC QLQ-CR29. Higher SF is an indication of bowel function impairment. ACS score at enrollment was examined in relation to SF at enrollment and over a 3-year period. Secondarily, we examined associations between the ACS score components (body mass index, dietary factors, and physical activity) and SF. Multivariable models were adjusted for demographic and surgical characteristics. Results A total of 112 people with colon cancer (59% women, mean age 59.5 years) were included. Cross-sectionally, for every point increase in ACS score at enrollment, the odds of having frequent stools at enrollment decreased by 43% (CI 0.42–0.79; p Conclusions Colon cancer survivors who more closely followed the ACS nutrition and physical activity guidelines had lower SF, an indication of better bowel function. Implications for Cancer Survivors Our findings highlight the value of interventions that support health behavior modification as part of survivorship care for long-term colon cancer survivors.

Highlights • Bowel resection is associated with decreased three-year survival. • Bowel resection does not impact progression free survival. • Bowel resection is associated with significant peri-operative complication. • Sequelae of peri-operative morbidity may contribute to decreased survival. • Bowel resection may be a surrogate for worse tumor molecular subtype., Objectives To evaluate the impact of bowel resection at the time of interval cytoreductive surgery on survival. Methods We identified patients with advanced ovarian cancer who underwent neoadjuvant chemotherapy and interval cytoreductive surgery between 2008 and 2018 from a single-institution tumor registry. Kaplan-Meier survival analysis and Cox proportional hazards models were performed comparing patients who underwent bowel resection to those who did not. Results Of 158 patients, 43 (27%) underwent bowel resection. Rates of optimal (95%) and sub-optimal (5%) resection did not differ with bowel resection. Patients that required bowel resection had worse three-year survival (43% vs. 63%), even after adjusting for confounding variables of age, stage, number of neoadjuvant cycles, R0 resection, and ASA score (HR 2.27, p

Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials.We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection.We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years.This was a multicenter trial.Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge.Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy.Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention.This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34).The predetermined sample size to adequately reduce the risk of type II error was not achieved.Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560.ANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero).

ObjectiveThe purpose of this study was to determine if extended PET acquisition times in the pelvis during PET/MRI increase detection rates of potentially metastatic lymph nodes in patients with rectal cancer.Materials and methodsOur study was approved by the institutional review board of the University of California, San Francisco. Twenty-two patients with biopsy-proven rectal cancer underwent imaging via simultaneous 3-T time-of-flight PET/MRI, with seven undergoing two separate PET/MRI examinations, for a total of 29 studies. Each examination included both a whole-body PET/MRI and a dedicated pelvic PET/MRI with both 3- and 15-minute PET acquisitions for the pelvis. Three radiologists interpreted each examination with PET only, MRI only, then combined PET and MRI examinations, using all available images. Additionally, the 3- and 15-minute PET acquisitions of the pelvis were reviewed separately by a single radiologist.ResultsA total of 94 lymph nodes were identified as abnormal on PET, all with MRI anatomic correlates. Of these, 37 (39.4%) were seen only on the dedicated 15-minute acquisition. Fifty-seven (60.6%) nodes measured 5 mm or less, including 29 (30.9%) seen only on the 15-minute acquisition. Thirty-one (33.0%) nodes measured 5.1-10 mm, including eight (25.8%) seen only on the 15-minute acquisition. Of the 17 subjects imaged for initial staging, 11 (64.7%) were upstaged as a result of the increased PET acquisition time (10 from N1 to N2 and one from N0 to N1).ConclusionLonger PET acquisition times during PET/MRI for rectal cancer increases the number of FDG-avid lymph nodes detected without increasing scan time.

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. This Clinical Practice Guidelines Committee is charged with leading internationa

PurposeWe aimed to described 25-hydroxyvitamin D [25(OH)D] levels in newly diagnosed colorectal cancer (CRC) patients and to re-evaluate levels after chemotherapy.MethodsPermanent residents of the San Francisco Bay Area with a new CRC diagnosis of any stage were recruited prior to any non-surgical therapy. Serum 25(OH)D levels were measured at time of diagnosis and 6-month follow-up. Supplement use was not restricted. The primary endpoint was the frequency of vitamin D deficiency in patients with newly diagnosed CRC of all stages. The Kruskal-Wallis and Spearman correlation tests were used to evaluate associations of patient characteristics with 25(OH)D levels.ResultsMedian 25(OH)D level at baseline was 27.0ng/mL (range 7.2, 59.0); 65% of patients had insufficient levels (25(OH)D

Up to 30% of patients who have ulcerative colitis are faced with the complex decision between end ileostomy and IPAA. We developed a decision aid to encourage shared decision making between patients and surgeons.The aim of this study is to determine whether a decision aid is effective and acceptable for surgical patients with ulcerative colitis and their treating surgeons.This was a prospective cohort study.Patients and surgeons were enrolled from 3 colorectal surgery clinics.Consecutive adult patients with ulcerative colitis who were candidates for IPAA and end ileostomy were selected.Patients used a multilingual decision aid before meeting with the surgeon.We measured changes in knowledge, treatment preference, and stage of decision making, as well as preparation for decision making, patient satisfaction, and surgeon satisfaction after using the decision aid.Twenty-five patients were enrolled; 5 had previously undergone subtotal colectomy. After using the decision aid, patients' knowledge scores improved by 39% (p0.006), 6 patients changed their treatment preference, and 8 reported increased certainty in treatment preference. The median for preparation for decision making was 75 of 100. Patient satisfaction with the decision aid (median score, 37/41) and surgeon satisfaction with the clinical encounter (median score, 38/45) were high. Patients who previously underwent subtotal colectomy had lower preparation for decision-making scores (median score, 58 vs 78 for surgery-naïve patients, p = 0.06), and did not report increased certainty in treatment preference after using the decision aid.The study included a small sample with no comparison group.A novel decision aid for surgical patients with ulcerative colitis appears to be effective and acceptable in patients and surgeons from diverse clinical settings. Patients who have not yet initiated surgical treatment seem to benefit most. Future studies to validate the knowledge questionnaire and test the decision aid in a randomized fashion are warranted.

Bowel dysfunction, including frequency, fecal urgency, stool consistency, and evacuation symptoms, contributes to fecal incontinence.The purpose of this study was to examine the impact of a vaginal bowel control system on parameters of bowel function, including frequency, urgency, stool consistency, and evacuation.This was a secondary analysis of a multicenter, prospective clinical trial.This study was conducted at 6 sites in the United States, including university hospitals and private practices in urogynecology and colorectal surgery.A total of 56 evaluable female subjects aged 19 to 75 years with 4 or more fecal incontinence episodes on a 2-week bowel diary were included.The study intervention was composed of the vaginal bowel control system, consisting of a vaginal insert and pressure-regulated pump.Subjects completed a 2-week baseline diary of bowel function before and after treatment completed at 1 month. Fecal urgency, consistency of stool (Bristol score), and completeness of evacuation were recorded for all bowel movements.Use of the insert was associated with an improvement in bowel function across all 4 categories. Two thirds (8/12) of subjects with a high frequency of daily stools (more than 2 per day) shifted to a normal or low frequency of stools. Analysis of Bristol stool scale scores demonstrated a significant reduction in the proportion of all bowel movements reported as liquid (Bristol 6 or 7), from 36% to 21% (p = 0.0001). On average, 54% of stools were associated with urgency at baseline compared with 26% at 1 month (p0.0001). Incomplete evacuations with all bowel movements were reduced from 39% to 26% of subjects at 1 month (p = 0.0034).The study follow-up period was 1 month (with an optional additional 2 months).The vaginal bowel control system was associated with an improvement in bowel symptoms and function, including reduced bowel movement frequency, less fecal urgency, increased solid consistency, and improved evacuation in patients with significant fecal incontinence.

OBJECTIVES We previously showed that management with a novel vaginal bowel control system was efficacious in women with moderate to severe fecal incontinence. The objective of this secondary analysis was to evaluate the clinical characteristics associated with device-fitting success. METHODS This is a secondary analysis of an institutional review board-approved, multicenter, prospective, open-label clinical study of women aged 19 to 75 years with 4 or more episodes of fecal incontinence recorded on a 2-week baseline bowel diary. Those successfully fitted with the vaginal bowel control device entered a 1-month treatment period, and efficacy was assessed with a repeat bowel diary. Demographic data, medical and surgical history, and pelvic examination findings were compared across women with successful and unsuccessful completion of the fitting period. Multivariate logistic regression analysis was performed. RESULTS Six clinical sites in the United States recruited from August 2012 through October 2013. Overall, 110 women underwent attempted fitting, of which 61 (55.5%) of 110 were successful and entered the treatment portion of the study. Multivariate logistic regression analysis revealed that previous prolapse surgery (P = 0.007) and shorter vaginal length (P = 0.041) were independently associated with unsuccessful fitting. Women who have not undergone previous prolapse surgery had 4.7 times the odds (95% confidence interval [CI], 1.53-14.53) of a successful fit. In addition, for every additional centimeter of vaginal length, women had 1.49 times the odds (95% CI, 1.02-2.17) of a successful fit. CONCLUSIONS Shorter vaginal length and previous prolapse surgery were associated with an increased risk of fitting failure. These findings may be used to inform patients regarding their expectation of successful fitting.

BACKGROUND: Adding modified FOLFOX6 (folinic acid, fluorouracil, oxaliplatin) after chemoradiotherapy and lengthening the chemoradiotherapy-to-surgery interval is associated with an increase in the proportion of rectal cancer patients with a pathological complete response. OBJECTIVE: To analyze disease-free and overall survival. DESIGN: Nonrandomized phase II trial. SETTINGS: Multi-institutional. PATIENTS: Four sequential study groups with stage II or III rectal cancer. INTERVENTION: All patients received 50 Gy of radiation with concurrent continuous infusion of fluorouracil for 5 weeks. Patients in each group received 0, 2, 4, or 6 cycles of modified FOLFOX6 after chemoradiation and before total mesorectal excision. Patients were recommended to receive adjuvant chemotherapy after surgery to complete a total of 8 cycles of modified FOLFOX6. MAIN OUTCOME MEASURES: The trial was powered to detect differences in pathological complete response, which was reported previously. Disease-free and overall survival are the main outcomes for the current study. RESULTS: Of 259 patients, 211 had a complete follow-up. Median follow-up was 59 months (range, 9–125). The mean number of total chemotherapy cycles differed between the four groups (p = 0.002), as one third of patients in the group assigned to no preoperative FOLFOX did not receive any adjuvant chemotherapy. Disease-free survival was significantly associated with study group, ypTNM stage, and pathological complete response (p = 0.004

Background Although social support is important for quality of life in patients undergoing surgery for ulcerative colitis, the impact of surgery on patient relationships is not known. Objective We examined relationship parameters in patients with ulcerative colitis and their partners before and 6 months after surgery. Design This was a prospective cohort in which we performed an exploratory analysis. Settings Patients were enrolled from an academic medical center. Patients Surgical patients with ulcerative colitis and their partners were invited to participate. Interventions Patients underwent proctocolectomy in 1, 2, or 3 stages. Main outcome measures We measured quality of life and sexual function in patients, as well as relationship quality, empathy, and sexual satisfaction in patients and partners before and 6 months after surgery using validated questionnaires. Results The study sample consisted of 74 participants, including 37 patients (25 men and 12 women) and their opposite-sex partners. Quality of life improved significantly in male and female patients after surgery. Sexual function scores also improved after surgery in male and female patients; however, the changes reached statistical significance in male patients only. Sexual satisfaction scores improved significantly after surgery in female patients and their partners. There was little change in relationship quality or empathy after surgery, with the exception of slightly improved relationship quality reported by male partners. In general, patients and partners reported levels of relationship quality and empathy similar to normative populations. Limitations This study included a small, highly selected sample. Conclusions Male and female patients with ulcerative colitis have high-quality relationships that are not negatively affected by surgical treatment. Changes in sexual function do not necessarily coincide with changes in sexual satisfaction in this patient population. Future studies should evaluate the effect of high-quality relationships on surgical outcomes.

Up to 30% of patients who underwent surgical treatment for rectal prolapse will experience a recurrence. The presentation and evaluation of recurrent rectal prolapse is similar to that of primary rectal prolapse. The options for surgical treatment are the same as those for primary disease, and similarly, there is no widely accepted gold standard. Several factors are considered when choosing an approach, such as the patient׳s previous surgical history, age, functional status, and comorbid pelvic floor disorders such as fecal incontinence and constipation. Abdominal and perineal approaches have been described. The ideal procedure for each patient is that which has the longest durability and best functional outcome while minimizing surgical morbidity. Future prospective studies that critically evaluate outcomes are needed to guide procedure choice.

Background Evidence from single-center studies suggests that ileal pouch-anal anastomosis (IPAA) can be safely performed in selected older patients with ulcerative colitis. The impact of age and frailty on surgical outcomes and hospital length of stay after IPAA has not been examined. Methods We identified all patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with IPAA in the National Surgery Quality Improvement Program database from 2005–2012. We examined the associations of age and frailty trait count with length of hospital stay and surgical complications using multivariate regression. Results IPAA was performed in 2493 patients with ulcerative colitis. Thirty-day mortality was 0.2% (n = 6). The majority of patients had no serious postoperative complications (age ≤50 y: 79.5%, age 51–60 y: 80.4%, and age >60 y: 79.1%). After multivariate risk adjustment, patients aged >60 y had a similar mean number of complications as patients aged ≤50 y (0.31 versus 0.35, P = 0.47) and a 0.8-d longer mean length of hospital stay (7.4 versus 8.2 d, P = 0.035). Compared to patients with zero frailty traits, a frailty trait count ≥1 was associated with a similar mean number of complications (0.31 versus 0.34, P = 0.36) and length of hospital stay (7.4 versus 7.7 d, P = 0.25). Conclusions In this analysis of patients undergoing IPAA at National Surgery Quality Improvement Program hospitals, surgical complications were not substantially increased in older patients or those with frailty traits. Older age was associated with a small increase in hospital length of stay. These findings suggest that IPAA is safe in selected older adults with ulcerative colitis.

Aim Little is known about men with faecal incontinence. We compared clinical findings and quality of life in a large cohort of men and women with faecal incontinence to guide its evaluation and treatment in men. Method We analysed men and women presenting to a tertiary referral centre with faecal incontinence between 2005 and 2013. Demographics, physical examination, anorectal physiology testing, symptom severity (Fecal Incontinence Severity Index) and quality of life (Fecal Incontinence Quality of Life Scale) were recorded. We determined differences between men and women and analysed the association between gender and quality of life. Results Data were obtained from 144 men and 897 women. Men with faecal incontinence were slightly younger than women (55.3 vs 57.6 years, P = 0.001), more likely to report coexisting constipation (P = 0.004) and more likely to have normal internal and external sphincter function on physical examination (both P

Background Repair of grade 3 and grade 4 ventral hernias is a distinct challenge, given the potential for infection, and the comorbid nature of the patient population. This study evaluates our institutional outcomes when performing single-stage repair of these hernias, with biologic mesh for abdominal wall reinforcement. Methods A prospectively maintained database was reviewed for all patients undergoing repair of grade 3 (potentially contaminated) or grade 4 (infected) hernias, as classified by the Ventral Hernia Working Group. All those patients undergoing repair with component separation techniques and biologic mesh reinforcement were included. Patient demographics, comorbidities, and postoperative complications were analyzed. Univariate analysis was performed to define factors predictive of hernia recurrence and wound complications. Results A total of 41 patients underwent single-stage repair of grade 3 and grade 4 hernias during a 4-year period. The overall postoperative wound infection rate was 15%, and hernia recurrence rate was 12%. Almost all recurrences were seen in grade 4 hernia repairs, and in those patients undergoing bridging repair of the hernia. One patient required removal of the biologic mesh. Those factors predicting hernia recurrence were smoking (P = 0.023), increasing body mass index (P = 0.012), increasing defect size (P = 0.010), and bridging repair (P = 0.042). No mesh was removed due to perioperative infection. Mean follow-up time for this patient population was 25 months. Conclusions Single-stage repair of grade 3 hernias performed with component separation and biologic mesh reinforcement is effective and offers a low recurrence rate. Furthermore, the use of biologic mesh allows for avoidance of mesh explantation in instances of wound breakdown or infection. Bridging repairs are associated with a high recurrence rate, as is single-stage repair of grade 4 hernias.

To evaluate the effectiveness and safety of a vaginal bowel-control device and pump system for fecal incontinence treatment.Women with a minimum of four fecal incontinence episodes over 2 weeks were fit with the intravaginal device. Treatment success, defined as a 50% or greater reduction of incontinent episodes, was assessed at 1 month. Participants were invited into an optional extended-wear period of another 2 months. Secondary outcomes included symptom improvement measured by the Fecal Incontinence Quality of Life, Modified Manchester Health Questionnaire, and Patient Global Impression of Improvement. Adverse events were collected. Intention-to-treat analysis included participants who were successfully fit entering treatment. Per protocol, analysis included participants with a valid 1-month treatment diary.Sixty-one of 110 (55.5%) participants from six clinical sites were successfully fit and entered treatment. At 1 month, intention-to-treat success was 78.7% (48/61, P.001); per protocol success, 85.7% (48/56, P.001) and 85.7% (48/56) considered bowel symptoms "very much better" or "much better." There was significant improvement in all Fecal Incontinence Quality of Life (P.001) and Modified Manchester (P≤.007) subscales. Success rate at 3 months was 86.4% (38/44; 95% confidence interval 73-95%). There were no serious adverse events; the most common study-wide device-related adverse event was pelvic cramping or discomfort (25/110 participants [22.7%]), the majority of events (16/25 [64%]) occurring during the fitting period.In women successfully fit with a vaginal bowel-control device for nonsurgical treatment for fecal incontinence, there was significant improvement in fecal incontinence by objective and subjective measures.ClinicalTrials.gov, www.clinicaltrials.gov, NCT01655498.: II.

This is the second of a two-part summary of a National Institutes of Health conference on fecal incontinence (FI) that summarizes current treatments and identifies research priorities. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback, often recommended as first-line treatment after conservative management fails, produces satisfaction with treatment in up to 76% and continence in 55%; however, outcomes depend on the skill of the therapist, and some trials are less favorable. Electrical stimulation of the anal mucosa is ineffective, but continuous electrical pulsing of sacral nerves produces a ≥50% reduction in FI frequency in a median 73% of patients. Tibial nerve electrical stimulation with needle electrodes is promising but remains unproven. Sphincteroplasty produces short-term clinical improvement in a median 67%, but 5-year outcomes are poor. Injecting an inert bulking agent around the anal canal led to ≥50% reductions of FI in up to 53% of patients. Colostomy is used as a last resort because of adverse effects on quality of life. Several new devices are under investigation but not yet approved. FI researchers identify the following priorities for future research: (1) trials comparing the effectiveness, safety, and cost of current therapies; (2) studies addressing barriers to consulting for care; and (3) translational research on regenerative medicine. Unmet patient needs include FI in special populations (e.g., neurological disorders and nursing home residents) and improvements in behavioral treatments.

BACKGROUND The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes. METHODS Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed. RESULTS The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025). CONCLUSIONS Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

Background: Many studies have described using biofeedback to treat chronic constipation, but few reports have addressed its impact on quality of life (QOL). Objective: The aim was to evaluate the effect of biofeedback with a validated Constipation Severity Instrument (CSI) and Constipation-Related QOL (CRQOL) measure. Design: Prospectively collected data with retrospective analysis. Setting: Tertiary care academic center. Patients and Methods: Patients referred to the Center for Pelvic Physiology with chronic constipation and objective signs of pelvic floor dyssynergia, who received a complete course of biofeedback therapy and returned all of their questionnaires, were enrolled in the study. Questionnaires were given upon initial evaluation, immediately after the complete course of biofeedback, and 6 months later. Main Outcome Measures: Improvement of dyssynergia symptom and QOL by CSI and CRQOL. Sample Size: A total of 25 patients (20 females and 5 males) were included. Results: Overall, 75% of patients reported satisfactory symptom and QOL improvement. CSI total scores decreased after treatment (35.0 vs. 31.0, P = 0.06) and at 6-month follow-up (35.0 vs. 30.0, P = 0.05). Only the obstructive defecation (OD) subscale of CSI improved significantly after treatment (median 21.0 vs. 16.5, P

A search for narrow resonances decaying into dijet final states is performed on data from proton-proton collisions at a center-of-mass energy of 8 TeV, corresponding to an integrated luminosity of 18.8 fb(-1). The data were collected with the CMS detector using a novel technique called data scouting, in which the information associated with these selected events is much reduced, permitting collection of larger data samples. This technique enables CMS to record events containing jets at a rate of 1 kHz, by collecting the data from the high-level-trigger system. In this way, the sensitivity to low-mass resonances is increased significantly, allowing previously inaccessible couplings of new resonances to quarks and gluons to be probed. The resulting dijet mass distribution yields no evidence of narrow resonances. Upper limits are presented on the resonance cross sections as a function of mass, and compared with a variety of models predicting narrow resonances. The limits are translated into upper limits on the coupling of a leptophobic resonance Z'(B) to quarks, improving on the results obtained by previous experiments for the mass range from 500 to 800 GeV.

Background As the population ages, an increasing number of elderly persons will undergo surgery for rectal cancer. The use of sphincter-sparing surgery in frail older adults is controversial. Objective The aim of this study was to examine mortality and bowel function after proctectomy in nursing home residents. Design This is a retrospective cohort study. Setting This investigation was conducted in nursing homes in the United States contracted with the Center for Medicare and Medicaid Services. Patients Nursing home residents age 65 and older undergoing proctectomy for rectal cancer (2000-2005) were included. Main outcome measures The primary outcomes measured were fecal incontinence and the 1-year mortality rate. Results Operative mortality was 18% after proctectomy with permanent colostomy and 13% after sphincter-sparing proctectomy (adjusted relative risk, 1.25 (95% CI 0.90-1.73), p = 0.188). One-year mortality was high: 40% after sphincter-sparing proctectomy and 51% after proctectomy with permanent colostomy (adjusted hazard ratio 1.32 (95% CI 1.09-1.60), p = 0.004). After sphincter-sparing proctectomy, 37% of residents were incontinent of feces. Residents with the poorest functional status (Minimum Data Set-Activities of Daily Living quartile 4) were significantly more likely to be incontinent of feces than residents with the best functional status (Minimum Data Set-Activities of Daily Living quartile 1) (76% vs 13%, adjusted relative risk 3.28 (95% CI 1.74- 6.18), p= 0.0002). Fecal incontinence was also associated with dementia (adjusted relative risk 1.55 (95% CI 1.15-2.09), p = 0.004) and renal failure (adjusted relative risk 1.93 (95% CI 1.10-3.38), p = 0.022). Limitations Measures of fecal incontinence in nursing home registries are not as well studied as those commonly used in clinical practice. Conclusions Sphincter-sparing proctectomy in nursing home residents is frequently associated with postoperative fecal incontinence and should be considered only for continent patients with good functional status.

Aliment Pharmacol Ther 2012; 35: 183–192 Summary Background Chronic constipation is associated with impaired quality of life and physical discomfort. Although inability to engage in day-to-day activities has been significantly associated with psychological distress, limited research has examined this relationship in constipated samples. Aim To develop and validate the Constipation-Related Disability Scale (CRDS), which assesses the extent of disability caused by constipation. Methods A total of 240 constipated participants and 103 healthy controls completed the CRDS. Reliability was measured with Cronbach’s coefficient alpha and test–retest reliability was assessed with intraclass correlation coefficients. Convergent, divergent and predictive validity were assessed. Results Component and factor analyses were used to derive two factors: Work/Leisure Activities and Activities of Daily Living, as well as a total CRDS score. Good reliability was found, with alphas ≥0.87 and intraclass correlation coefficients ≥0.85. All scales were negatively correlated with the physical health subscales of the SF-36 (P

T he American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Rectal cancer response to chemoradiation (CRT) varies from no response to a pathologic complete response (pCR). Identifying predictive biomarkers of response would therefore be useful. We assessed whether chromosomal copy number alterations (CNAs) can assist in predicting pCR. Pretreatment tumor biopsies and paired normal surgical tissues from the proximal resection margin were collected from 95 rectal cancer patients treated with preoperative CRT and total mesorectal excision in a prospective Phase II study. Tumor and control DNA were extracted, and oligonucleotide array-based comparative genomic hybridization (aCGH) was used to identify CNAs, which were correlated with pCR. Ingenuity pathway analysis (IPA) was then used to identify functionally relevant genes in aberrant regions. Finally, a predictive model for pCR was built using support vector machine (SVM), and leave-one-out cross validation assessed the accuracy of aCGH. Chromosomal regions most commonly affected by gains were 20q11.21-q13.33, 13q11.32-23, 7p22.3-p22.2, and 8q23.3-q24.3, and losses were present at 18q11.32-q23, 17p13.3-q11.1, 10q23.1, and 4q32.1-q32.3. The 25 (26%) patients who achieved a pCR had significantly fewer high copy gains overall than non-pCR patients (P = 0.01). Loss of chromosomal region 15q11.1-q26.3 was significantly associated with non-pCR (P < 0.00002; Q-bound < 0.0391), while loss of 12p13.31 was significantly associated with pCR (P < 0.0003; Q-bound < 0.097). IPA identified eight genes in the imbalanced chromosomal regions that associated with tumor response. SVM identified 58 probes that predict pCR with 76% sensitivity, 97% specificity, and positive and negative predictive values of 91% and 92%. Our data indicate that chromosomal CNAs can help identify rectal cancer patients more likely to develop a pCR to CRT.

Rectovaginal and rectourethral fistulas occur infrequently but result in devastating complications to patients. They also pose unique challenges to the surgeons treating these fistulas. A thorough evaluation should be performed to determine the location, size, and etiology of the fistula that may include trauma, infection, inflammatory bowel diseases, radiation, postoperative complications, and malignancy. Some fistulas may close spontaneously but most require surgical treatment. The options for repair include transrectal, transvaginal, or transperineal approaches and transabdominal approaches. Successful management of these fistulas involves recognizing the etiology, location, local tissue quality, and overall medical health of patients.

PURPOSE The purpose of this study was to determine the influence of age on various characteristics of constipation. We also sought to determine if age, comorbid conditions, and specific clinical characteristics such as use of pain medications were associated with an increase in the frequency of constipation-associated symptoms. SUBJECTS AND SETTING The sample comprised 518 patients 18 years or older with a primary diagnosis of constipation. Subjects were drawn from the clinical database of all patients (n = 1228) referred from primary care or gastroenterology practices to the University of California, San Francisco Center for Pelvic Physiology between March 2003 and October 2007. DESIGN Cross-sectional study. INSTRUMENTS Patients completed 2 questionnaires. The clinical questionnaire obtained information on demographic characteristics and previous medical history. A second, investigator-developed questionnaire provided data about characteristics of constipation, symptoms of constipation, as well as various bowel and dietary habits. RESULTS : Both younger and middle-aged patients were more than twice as likely as older patients to have infrequent bowel movements and abdominal bloating and to use position changes to facilitate bowel evacuations. In addition, younger patients were nearly 3 times as likely to report abdominal pain as older patients. Patients with constipation who present at a younger age report a higher frequency of certain characteristics, symptoms, and bowel habits. CONCLUSIONS Screening of younger patients for this common problem is warranted.

Fecal incontinence and constipation are benign conditions that can have a significant effect on the lifestyles of those affected. In order for clinicians to better understand a patient's baseline symptoms and, more importantly, to have a measure that can evaluate and compare different treatments and their outcomes, patient-validated self-report tools that assess symptoms and quality of life are essential.

Various surgical options exist for patients with pelvic organ prolapse. Conventionally, open procedures have been performed laparoscopically with similar results and fewer morbidity. However, widespread use of laparoscopy to treat rectal and vaginal vault prolapse has been limited by the technical challenges of performing these surgeries with a minimally invasive approach. Robotic surgery allows for improved visualization and ergonomics, enabling the surgeon to perform complicated procedures more easily. Robotically assisted laparoscopic rectopexies and sacrocolpopexies have been shown to have excellent results but they increase operative time and cost. Further investigation is needed to demonstrate clear advantages to using this approach over conventional laparoscopy.

Few existing measures assess constipation-specific quality of life. This study sought to develop a valid and reliable quality-of-life measure for constipation.First, we created a preliminary instrument that assessed quality-of-life domains affected by constipation: body image, eating, mood, and relationships with others. We conducted focus groups both with patients with constipation seeking treatment and the health care providers who treat them. Next, a 59-item questionnaire was given to 240 subjects with constipation (83% female) and 103 healthy volunteers (63% female). Test-retest reliability and discriminant, convergent, and divergent validity were assessed.Exploratory factor analysis revealed four domains: Social Impairment (five items), Distress (six items), Eating Habits (three items), and Bathroom Attitudes (four items). Internal consistency and test-retest reliability for all subscales was high (Cronbach's alpha = 0.89; intraclass correlation coefficient = 0.87). All domains discriminated well between subjects with constipation and healthy volunteers (P0.001). Convergent validity was excellent: all subscales correlated highly with the Irritable Bowel Syndrome Quality of Life Scale total score (P0.001) and the Medical Outcomes Study Short Form-36 physical component and mental component summary scores (P0.001). Scores from our Constipation-Related Quality of Life measure were not significantly correlated with the Social Desirability Scale, demonstrating divergent validity.Our findings support the reliability and validity of the Constipation-Related Quality of Life measure. Future validation of the Constipation-Related Quality of Life measure for assessing changes in quality of life in response to treatments for constipation is needed.

Rectourethral fistula is a rare complication of pelvic surgery, trauma, or inflammation. The many techniques for repairing these fistulas vary in their success rates. Our goal was to describe the use of a dartos muscle interposition flap for repair of these fistulas. We performed a retrospective review of eight patients who underwent repair of a rectourethral fistula with a dartos muscle interposition flap. We describe the success rate and patient-related factors that may have affected success. The technique of dartos muscle interposition is described and compared with other previously described techniques. Six of eight patients had healing of their fistulas documented by follow-up cystogram. Dartos muscle interposition is a straightforward technique that can result in successful fistula repair but should not be used in patients with risk factors for poor wound healing, such as an immunocompromised state or previous radiation therapy.

Little is known about how obstructive defecation and colonic inertia symptoms contribute to constipation-related quality of life.We sought to characterize the differences in quality of life in patients with severe obstructive defecation and colonic inertia symptoms.This study was a cross-sectional analysis of a prospective database.Patients were enrolled at a single tertiary referral center.We included consecutive adults with severe symptoms of obstructive defecation (n = 115) or colonic inertia (n = 90) as measured by the Constipation Severity Instrument.The primary outcomes measured were the Pelvic Floor Distress Inventory, Constipation-Related Quality of Life instrument, Pelvic Floor Impact Questionnaire, and 12-item Short Form Health Survey.Although physical examination and anorectal physiology testing were similar between groups, patients with severe obstructive defecation symptoms reported worse pain, distress, and constipation-specific quality of life than patients with severe colonic inertia symptoms (all p0.001). Specifically, patients with severe obstructive defecation symptoms showed greater quality-of-life impairment related to eating, bathroom habits, and social functioning (all p ≤ 0.01). Furthermore, patients with severe obstructive defecation symptoms had inferior global quality of life on the 12-item Short Form Health Survey physical component score (p = 0.03) and mental component score (p = 0.06).The use of patient self-report instruments resulted in a proportion of patients with incomplete data.Quality of life was impaired in both groups of patients; however, patients with severe obstructive defecation symptoms were affected to a significantly greater extent. The fact that there were no differences in objective findings on physical examination or anorectal physiology studies highlights the importance of assessing quality of life during the evaluation and treatment of constipated patients.

BACKGROUND Historically, older patients with ulcerative colitis were not considered candidates for ileal pouch-anal anastomosis. However, more recent evidence suggests that this procedure can be performed in older patients with acceptable surgical and functional results. OBJECTIVE The purpose of this work was to determine whether older age is independently associated with surgical procedure type among patients with ulcerative colitis in a large national database. DESIGN This was a cross-sectional analysis of ulcerative colitis patients undergoing end ileostomy or IPAA, grouped by age. SETTINGS This study was conducted in a university teaching hospital. PATIENTS Patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with either IPAA or end ileostomy from 2005 to 2012 in the American College of Surgeons National Surgery Quality Improvement Program database were included in this study. MAIN OUTCOME MEASURES The primary outcome was procedure type (end ileostomy or IPAA). Patient factors associated with procedure type, including age and trends over time, were examined using multivariate logistic regression. RESULTS Among 3635 patients with ulcerative colitis, 28.2% underwent end ileostomy and 71.8% underwent IPAA. Older patients were more likely to undergo end ileostomy than patients ≤50 years of age after adjustment for sex, smoking, BMI, frailty trait count, and ASA class (p < 0.001). The odds of end ileostomy decreased by 12% per year between 2005 and 2012 in patients aged 61 to 70 years compared with patients ≤50 years of age (adjusted OR, 0.88 per year; p = 0.021). LIMITATIONS We were unable to analyze other potentially important determinants of procedure type, such as surgeon, patient preference, and anal sphincter integrity. CONCLUSIONS Age remains strongly associated with procedure type. The use of end ileostomy, however, is decreasing over time in patients 61 to 70 years of age as evidence accumulates that IPAA is an acceptable option for older patients with ulcerative colitis (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A191).

Diese Studie wurde durchgefuhrt, um bei ethnisch unterschiedlichen Frauen uber 40 Jahren die Pravalenz von Stuhlinkontinenz zu untersuchen sowie mit Stuhlinkontinenz assoziierte Risikofaktoren zu bestimmen. Die Studie „Reproductive Risks for Incontinence Study at Kaiser“ ist eine bevolkerungsbasierte Untersuchung von 2 109 willkurlich ausgewahlten Frauen mittleren Alters und alter (Durchschnittsalter 56 Jahre). Die Stuhlinkontinenz wurde mittels Patientenaussage festgestellt und nach der Haufigkeit ihres Auftretens eingestuft. Die Frauen berichteten uber den Grad der Belastung durch die Stuhlinkontinenz sowie ihre allgemeine Lebensqualitat. Potenzielle Risikofaktoren wurden durch Selbstbeurteilung, Befragung, eine korperliche Untersuchung und Prufung der Krankenakte beurteilt. Zur Feststellung der Unabhangigkeit von ausgesuchten Risikofaktoren und dem wesentlichen Ergebnis von jeder berichteten Stuhlinkontinenz im zuruckliegenden Jahr wurde die multivariate logistische Regressionsanalyse eingesetzt. 24% der Frauen gaben eine Stuhlinkontinenz in den letzten zwolf Monaten an (3,4% monatlich, 1,9% wochentlich, und 0,2% taglich). Eine grosere Haufigkeit von Stuhlinkontinenz war mit verringerter Lebensqualitat (Medical Outcome Short Form-36 Mental Component Scale Score, p = 0,01) sowie mit gestiegener Belastung (p < 0,001) assoziiert: so klagten 45% der Frauen mit Stuhlinkontinenz in den letzten zwolf Monaten und 100% der Frauen mit taglicher Stuhlinkontinenz uber eine masige oder grose Belastung. Bei der multivarianten Analyse stieg die Pravalenz von Stuhlinkontinenz im zuruckliegenden Jahr in Verbindung mit Adipositas [1,2 (1,1– 1,3)], chronisch obstruktiver Lungenerkrankung [1,9 (1,3–2,9)], Reizdarmsyndrom [2,4 (1,7–3,4)], Harninkontinenz [2,1 (1,7–2,6)] und Kolektomie [1,9 (1,1–3,1)] significoloproctology kant an [Odds Ratio per 5 kg/m2 (95% Konfidenzintervall)]. Latina-Frauen hatten eine geringere Wahrscheinlichkeit fur Stuhlinkontinenz als weise Frauen [0,6 (0,4– 0,9)]. Stuhlinkontinenz, ein alltagliches Frauenproblem, ist mit wesentlichen negativen Auswirkungen auf die Lebensqualitat verbunden. Einige der festgestellten Risikofaktoren sind vermeidbar oder modifizierbar und konnen den Verlauf der weiteren Forschung bei der Therapie der Stuhlinkontinenz beeinflussen.

Objective The gross extent of ulcerative colitis (UC) is a recognized risk factor for the development of colitis-related dysplasia and colorectal cancer (CRC). The risk of neoplasia associated with the microscopic extent of colitis is unknown. The aim of this study was to describe the gross and microscopic extent of colitis in patients with UC-related dysplasia/CRC. Methods All patients who underwent colectomy at our institution between 1992-2001 with colitis-related dysplasia/CRC were identified. Histological sections from each colectomy specimen were reviewed for the microscopic extent of colitis and the location of all lesions with dysplasia/CRC. Results Thirty-six patients with colitis-related dysplasia/CRC were identified of whom 30 had slides available for review. Gross pancolitis was identified in 19 patients, though microscopic pancolitis was evident in all 30 patients. Among the 11 patients with only distal gross colitis, 4/15 neoplastic lesions were proximal to the area of gross involvement. Conclusions UC-related neoplasia can occur in areas of the colon not grossly involved with colitis, though it did not occur in any patients without microscopic pancolitis. To devise rational cancer surveillance guidelines, further studies are needed to determine the risk of colitis-related neoplasia in patients with microscopic pancolitis but limited gross disease.

Receptor subtypes within families of G protein-coupled receptors that are activated by similar ligands can regulate distinct intracellular effectors. We identified conserved motifs within intracellular domains 2 and 3 of selective subtypes of several G protein-coupled receptor families that confer coupling to the Na-H exchanger, NHE1. A T(s,p)V motif within intracellular domain 2 and a QQ(r) motif within intracellular domain 3 are shared by the somatostatin receptor subtypes SSTR1, -3, and -4, which couple to the inhibition of NHE1, but not by SSTR2 and -5, which do not signal to NHE1. Only the collective substitution of cognate SSTR2 residues with these two motifs conferred the ability of mutant SSTR2 to inhibit NHE1. Both motifs are present in D(2)-dopamine receptors, which inhibit NHE1, and in alpha(2B)-adrenergic receptors, which couple to the inhibition of NHE1, but not in alpha(2A)-adrenergic receptors, which do not regulate NHE1. These findings indicate that motifs shared by different subfamilies of G protein-coupled receptors, but not necessarily by receptor subtypes within a subfamily, can confer coupling to a common effector.

A collaborative effort among the 5 Universities of California (UC) Institutions was convened in November of 2011 to focus on opportunities for improvement in care of patients with benign and malignant colorectal diseases. Colorectal surgeons and other interested parties were present. Goals of the collaborative meeting included the following: to broaden our knowledge about geographically diverse patients at the different UC institutions, to integrate clinical research and care across the UC campuses to improve diagnosis and treatment of benign and malignant colorectal disease, to evaluate our current standard of care in colorectal surgery and develop interventions to improve quality of care, to develop multidisciplinary and multi-institutional conferences that would allow us to advance our knowledge of patients with unusual diseases, and to promote surgical education and training via exchange programs. The collaborative effort has strong leadership from all the UCs, an in-progress UC-wide data collection program, and resources from the successful implementation of a UC-wide breast health care system, all of which will help ensure a successful colorectal collaborative program.

793 Background: A growing body of literature suggests that 25-hydroxyvitamin D [25(OH)D] levels are inversely related to the risk of developing CRC and that deficiency is associated with CRC-specific mortality. Due to the unique racial-ethnic diversity and UV exposure patterns of the San Francisco Bay Area, we aimed to evaluate vitamin D levels among our CRC patients at time of diagnosis and during treatment. Methods: Permanent residents of the SF Bay Area with a new diagnosis of CRC of any stage were recruited between 2011 and 2015 prior to initiation of therapy. Self-reported data on sun exposure, diet, and exercise patterns were collected. Clinical data including disease stage and primary tumor location were abstracted from charts. Serum 25(OH)D levels at time of diagnosis and at 6-month follow-up were batched and measured using the Liaison XL assay (Heartland Assays). Supplement use was not restricted. Kruskal-Wallis and Pearson correlation tests were used for categorical or continuous variables, respectively, to evaluate the associations of patient characteristics with 25(OH)D levels. Results: Among 94 patients with a new diagnosis of CRC, median 25(OH)D level at baseline was 27.0 ng/mL (range 7.2-59.0); 26% had deficient levels (