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Aim: Local excision (LE) for T1 rectal cancer may be recommended in those with low-risk disease, while resection is typically recommended in those with a high risk of luminal recurrence or lymph node metastasis. The aim of this work was to compare survival between resection and LE., Method: This was a population-based retrospective cohort study set in the Canadian province of Ontario. Patients were individuals with T1Nx rectal cancer between 2010 and 2014 and demographics, disease characteristics, treatments and outcomes were determined using linked administrative databases. This study does not include clinical information regarding individual patient treatment decisions. The main outcome measure was overall survival (OS)., Results: A total of 719 patients were identified, including 359 with upfront resection, 113 with LE and immediate resection (<90 days) and 247 with LE with definitive intent. The majority of LEs were performed via colonoscopy. Piecemeal excision (42% vs. 49%, p = 0.28) and positive margin (50% vs. 77%, p < 0.01) rates were high in both LE groups, with the highest rate in those with immediate resection. The prevalence of poor differentiation (<5%, p = 0.70) and lymphovascular invasion (LVI) (14%, p = 0.80) was similar across groups. In those with LE with definitive intent, 21% ultimately underwent resection (median 150 days, interquartile range 114-181 days) and 4% received radiation. There was no difference in 5-year OS between groups (resection 83.2% vs. LE and immediate resection 82.3% vs. definitive LE 83.3%; p = 0.33). Adjusted analyses demonstrated no association between approach and survival [definitive intent LE hazard ratio (HR) 0.97 (95% CI 0.70-1.35), LE and immediate resection HR 0.97 (95% CI 0.60-1.45), upfront resection HR 1 (Ref); p = 0.98]. Differentiation, piecemeal excisions and LVI were not associated with OS in the LE groups., Conclusion: There were no observed differences in survival between those who underwent resection, LE and immediate resection and definitive intent LE. Although, these are observational data, they call into question the reflexive decision to offer radical resection for those with suspected T1 rectal cancer., (© 2025 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Aim: In contrast to significant advances in organ preservation in locally advanced rectal cancer, the contemporary management of early-stage rectal cancer, including the frequency of abdominoperineal resections, remains largely unexplored in the United States. Therefore, we assessed the utilization of neoadjuvant therapy and oncological resections in early-stage rectal cancer patients., Study Design: This is a retrospective cohort study of patients with cT1-T3N0 rectal cancer who underwent proctectomies between 2016 and 2022 in the National Surgical Quality Improvement Project proctectomy files. Multivariable logistic regression was used to identify factors associated with abdominoperineal resections and Kendall's tau statistics to evaluate clinical-pathological staging agreement., Results: In all, 3078 patients (29.6% cT1-2N0, 70.4% cT3N0) were included with 55.3% of tumours <5 cm from the anal verge. Overall, 58.2% received neoadjuvant therapy within 3 months of surgery (30.6% for cT1-T2N0 vs. 69.8% for cT3N0, P < 0.001), and 58.6% underwent abdominoperineal resection (55.5% for cT1-T2N0 vs. 59.9% for cT3N0, P = 0.058). The adjusted odds of undergoing abdominoperineal resection were associated with increasing age (OR 1.4 per every 10-year increase; 95% CI 1.2-1.5), cT3N0 tumours (OR 1.7; 95% CI 1.1-2.7) and tumour location <5 cm from the anal verge (OR 10.6; 95% CI 7.7-14.7). There was a weak clinical-pathological T staging correlation (Kendal tau coefficient 0.25; 95% CI 0.20-0.29)., Conclusion: In this large cohort of patients with early-stage rectal cancer with high rates of neoadjuvant therapy, over half of patients underwent abdominoperineal resection and one in five had a pathological complete response. These findings underscore opportunities for organ preservation in early-stage rectal cancer, suggesting that treatments typically reserved for locally advanced disease may extend to early stages with the completion of ongoing clinical trials., (© 2025 Association of Coloproctology of Great Britain and Ireland.)

Aim: The aim of this study was to assess the short-term outcomes of robotic colorectal surgery implemented through a structured, standardized training pathway in five colorectal centres in the United Kingdom., Method: A multicentre retrospective observational study was conducted, involving 523 consecutive patients who underwent robotic colorectal resection between 2015 and 2019. All participating centres followed the European Academy of Robotic Colorectal Surgery training pathway. Patient data, including demographics, operative details, postoperative outcomes and pathology results, were collected and analysed., Results: The study included 447 rectal resections and 76 colonic operations. The median age of the patients was 64.7 years, with the majority of patients (70%) being men. The mean body mass index was 27.4 kg/m 2 , and 89.7% of the patients underwent surgery for malignancy. The overall conversion rate to open surgery was 4.2%. The median length of stay was 6 days and there was no 30-day mortality. The readmission and reoperation rates were 8.8% and 7.3%, respectively. The anastomotic leak rate was 4.1% for rectal resections and 3.9% for colonic resections. Pathological examination showed a positive circumferential resection margin rate of 2.6%., Conclusion: Through the implementation of a structured, standardized training pathway, the participating colorectal centres in the UK achieved safe and effective robotic colorectal surgery pathways with favourable short-term oncological and clinical outcomes. Further studies examining long-term and functional outcomes are needed to assess the broader impact of robotic surgery in colorectal procedures., (© 2024 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: We aimed to evaluate outcomes of organ preservation by local excision (LE) compared to proctectomy following neoadjuvant therapy for rectal cancer., Methods: This retrospective observational study using the National Cancer Database (NCDB) included patients with locally advanced non-metastatic rectal cancer (ypT0-1 tumors) treated with neoadjuvant therapy between 2004 and 2019. Outcomes of patients who underwent LE or proctectomy were compared. 1:1 propensity score matching including patient demographics, clinical and therapeutic factors was used to minimize selection bias. Main outcome was overall survival (OS)., Results: 11,256 of 318,548 patients were included, 526 (4.6%) of whom underwent LE. After matching, mean 5-year OS was similar between the groups (54.1 vs. 54.2 months; p = 0.881). Positive resection margins (1.2% vs. 0.6%; p = 0.45), pathologic T stage (p = 0.07), 30-day mortality (0.6% vs. 0.6%; p = 1), and 90-day mortality (1.5% vs. 1.2%; p = 0.75) were comparable between the groups. Length of stay (1 vs. 6 days; p < 0.001) and 30-day readmission rate (5.3% vs. 10.3%; p = 0.02) were lower in LE patients. Multivariate analysis of predictors of OS demonstrated male sex (HR 1.38, 95% CI 1.08-1.77; p = 0.009), higher Charlson score (HR 1.52, 95% CI 1.29-1.79; p < 0.001), poorly differentiated carcinoma (HR 1.61, 95% CI 1.08-2.39; p = 0.02), mucinous carcinoma (HR 3.53, 95% CI 1.72-7.24; p < 0.001), and pathological T1 (HR 1.45, 95% CI 1.14-1.84; p = 0.002) were independent predictors of increased mortality. LE did not correlate with worse OS (HR 0.91, 95% CI 0.42-1.97; p = 0.82)., Conclusion: Our findings show no overall significant survival difference between LE and total mesorectal excision, including ypT1 tumors. Moreover, patients with poorly differentiated or mucinous adenocarcinomas generally had poorer outcomes, regardless of surgical method., (© 2024. The Author(s).)

Introduction: Despite being a key metric with a significant correlation with the outcomes of patients with rectal cancer, the optimal surgical approach for total mesorectal excision (TME) has not yet been identified. The aim of this study was to assess the association of the surgical approach on the quality of TME and surgical margins and to characterize the surgical and long-term oncologic outcomes in patients undergoing robotic, laparoscopic, and open TME for rectal cancer., Methods: Patients with primary, nonmetastatic rectal adenocarcinoma who underwent either lower anterior resection or abdominoperineal resection via robotic (Rob), laparoscopic (Lap), or open approaches were selected from the US Rectal Cancer Consortium database (2007-2017). Quasi-Poisson regression analysis with backward selection was used to investigate the relationship between the surgical approach and outcomes of interest., Results: Among the 664 patients included in the study, the distribution of surgical approaches was as follows: 351 (52.9%) underwent TME via the open approach, 159 (23.9%) via the robotic approach, and 154 (23.2%) via the laparoscopic approach. There were no significant differences in baseline demographics among the three cohorts. The laparoscopic cohort had fewer patients with low rectal cancer (<6 cm from the anal verge) than the robotic and open cohorts (Lap 28.6% versus Rob 59.1% versus Open 45.6%, P = 0.015). Patients who underwent Rob and Lap TME had lower intraoperative blood loss compared with the Open approach (Rob 200 mL [Q1, Q3: 100.0, 300.0] versus Lap 150 mL [Q1, Q3: 75.0, 250.0] versus Open 300 mL [Q1, Q3: 150.0, 600.0], P < 0.001). There was no difference in the operative time (Rob 243 min [Q1, Q3: 203.8, 300.2] versus Lap 241 min [Q1, Q3: 186, 336] versus Open 226 min [Q1, Q3: 178, 315.8], P = 0.309) between the three approaches. Postoperative length of stay was shorter with robotic and laparoscopic approach compared to open approach (Rob 5.0 d [Q1, Q3: 4, 8.2] versus Lap 5 d [Q1, Q3: 4, 8] versus Open 7.0 d [Q1, Q3: 5, 9], P < 0.001). There was no statistically significant difference in the quality of TME between the robotic, laparoscopic, and open approaches (79.2%, 64.9%, and 64.7%, respectively; P = 0.46). The margin positivity rate, a composite of circumferential margin and distal margin, was higher with the robotic and open approaches than with the laparoscopic approach (Rob 8.2% versus Open 6.6% versus Lap 1.9%, P = 0.17), Rob versus Lap (odds ratio 0.21; 95% confidence interval 0.05, 0.83) and Rob versus Open (odds ratio 0.5; 95% confidence interval 0.22, 1.12). There was no difference in long-term survival, including overall survival and recurrence-free survival, between patients who underwent robotic, laparoscopic, or open TME (Figure 1)., Conclusions: In patients undergoing surgery with curative intent for rectal cancer, we did not observe a difference in the quality of TME between the robotic, laparoscopic, or open approaches. Robotic and open TME compared to laparoscopic TME were associated with higher margin positivity rates in our study. This was likely due to the higher percentage of low rectal cancers in the robotic and open cohorts. We also reported no significant differences in overall survival and recurrence-free survival between the aforementioned surgical techniques., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Aim: Literature on nationwide long-term permanent stoma rates after rectal cancer resection in the minimally invasive era is scarce. The aim of this population-based study was to provide more insight into the permanent stoma rate with interhospital variability (IHV) depending on surgical technique, with pelvic sepsis, unplanned reinterventions and readmissions as secondary outcomes., Method: Patients who underwent open or minimally invasive resection of rectal cancer (lower border below the sigmoid take-off) in 67 Dutch centres in 2016 were included in this cross-sectional cohort study., Results: Among 2530 patients, 1470 underwent a restorative resection (58%), 356 a Hartmann's procedure (14%, IHV 0%-42%) and 704 an abdominoperineal resection (28%, IHV 3%-60%). Median follow-up was 51 months. The overall permanent stoma rate at last follow-up was 50% (IHV 13%-79%) and the unintentional permanent stoma rate, permanent stoma after a restorative procedure or an unplanned Hartmann's procedure, was 11% (IHV 0%-29%). A total of 2165 patients (86%) underwent a minimally invasive resection: 1760 conventional (81%), 170 transanal (8%) and 235 robot-assisted (11%). An anastomosis was created in 59%, 80% and 66%, with corresponding unintentional permanent stoma rates of 12%, 24% and 14% (p = 0.001), respectively. When corrected for age, American Society of Anesthesiologists classification, cTNM, distance to the anorectal junction and neoadjuvant (chemo)radiotherapy, the minimally invasive technique was not associated with an unintended permanent stoma (p = 0.071) after a restorative procedure., Conclusion: A remarkable IHV in the permanent stoma rate after rectal cancer resection was found. No beneficial influence of transanal or robot-assisted laparoscopy on the unintentional permanent stoma rate was found, although this might be caused by the surgical learning curve. A reduction in IHV and improving preoperative counselling for decision-making for restorative procedures are required., (© 2024 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Aim: The aim of this work was to determine racial disparities in access to minimally invasive proctectomy using a national database., Method: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program evaluated for surgical approach (robotic, laparoscopic or open), demographics and comorbidity, and then compared by race., Results: A total of 3511 patients (325 Asian, 2925 White, 261 African American/Black) with cancer who underwent a proctectomy between 2016 and 2020 were included. Both Asians and Whites had significantly higher rates of laparoscopic proctectomy relative to African Americans (38.5%, 33.8% and 28.7%, respectively; p = 0.0001). Asians had the highest rate of robotic proctectomy (38.2%, p = 0.0001). Conversely, Black patients had significantly higher rates of open proctectomy followed by Whites and then Asians (42.1%, 35.4% and 23.4%, respectively; p = 0.0001). In multivariable logistic regression with backward elimination, African Americans were 0.7 times as likely to undergo laparoscopic proctectomy and 1.4 times more likely to undergo open proctectomy than Whites (p = 0.043). Compared with Whites, Asians were 1.8, 1.7 and 1.9 times more likely to undergo minimally invasive, laparoscopic proctectomy and robotic proctectomy, respectively (p = 0.0001, p = 0.001, p = 0.0001)., Conclusion: Asians had the highest rate of laparoscopic and robotic proctectomy, while Blacks had the highest rate of open proctectomy. African Americans were least likely to undergo laparoscopic proctectomy compared with all races. Race is an independent risk factor for access to minimally invasive proctectomy., (© 2024 Association of Coloproctology of Great Britain and Ireland.)

Aim: Preoperative frailty has been associated with adverse postoperative outcomes in various populations, but of its use in patients with inflammatory bowel disease (IBD) remains sparse. The present study aimed to characterize the impact of frailty, as measured by the modified frailty index (mFI), on postoperative clinical and resource utilization outcomes in patients with IBD., Methods: This retrospective population-based cohort study assessed patients from the National Inpatient Sample database from 1 September 2015 to 31 December 2019. Corresponding International Classification of Diseases 10th Revision Clinical Modification codes were used to identify adult patients (>18 years of age) with IBD, undergoing either small bowel resection, colectomy or proctectomy. Patient demographics and institutional data were collected for each patient to calculate the 11-point mFI. Patients were categorized as either frail or robust using a cut-off of 0.27. Primary outcomes were postoperative in-hospital morbidity and mortality, whilst secondary outcomes included system-specific morbidity, length of stay, in-hospital healthcare costs and discharge disposition. Logistic and linear regression models were used for primary and secondary outcomes., Results: Overall, 7144 patients with IBD undergoing small bowel resection, colectomy or proctectomy were identified, 337 of whom were classified as frail (i.e., mFI < 0.27). Frail patients were more likely to be women, older, have lower income and a greater number of comorbidities. After adjusting for relevant covariates, frail patients were at greater odds of in-hospital mortality (adjusted odds ratio [aOR] 5.42, 95% CI 2.31-12.77, P < 0.001), overall morbidity (aOR 1.72, 95% CI 1.30-2.28, P < 0.001), increased length of stay (adjusted mean difference 1.3 days, 95% CI 0.09-2.50, P = 0.035) and less likely to be discharged to home (aOR 0.59, 95% CI 0.45-0.77, P < 0.001) compared to their robust counterparts., Conclusions: Frail IBD patients are at greater risk of postoperative mortality and morbidity, and reduced likelihood of discharge to home, following surgery. This has implications for clinicians designing care pathways for IBD patients following surgery., (© 2024 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: Although high volume centers (HVC) equate to improved outcomes in rectal cancer, the impact of surgical volume related to race is less defined., Methods: Patients who underwent surgical resection for stage I-III rectal adenocarcinoma were divided into cohorts based on race and hospital surgical volume. Outcomes were analyzed following 1:1 propensity-score matching using logistic, Poisson, and Cox regression analyses with marginal effects., Results: Fifty-four thousand one hundred and eighty-four (91.5%) non-Black and 5043 (8.5%) Black patients underwent resection of rectal cancer. Following 1:1 matching of non-Black (N = 5026) and Black patients, 5-year overall survival (OS) of Black patients was worse (72% vs. 74.4%, average marginal effects [AME] 0.66, p = 0.04) than non-Black patients. When compared to non-Black patients managed at HVCs, Black patients had worse OS (70.1% vs. 74.7%, AME 1.55, p = 0.03), but this difference was not significant when comparing OS between non-Black and Black patients managed at HVCs (72.3% vs. 74.7%, AME 0.62, p = 0.06). Length of stay was longer among Black and HVC patients across all cohorts. There was no difference across cohorts in 90-day mortality., Conclusions: Although racial disparities exist in rectal cancer, this disparity appears to be ameliorated when patients are managed at HVCs., (© 2021 Wiley Periodicals LLC.)

Background: This study aims to measure the association between deprivation, health care accessibility and health care system with the likelihood of receiving non-restorative rectal cancer surgery (NRRCS)., Methods: All adult patients who had rectal resection for invasive adenocarcinoma diagnosed between 2007 and 2016 in four French specialised cancer registries were included. A multilevel logistic regression with random effect was used to assess the link between patient and health care structure characteristics on the probability of NRRCS., Results: 2997 patients underwent rectal cancer resection in 68 health care structures: 708 (23.63%) had NRRCS. The likelihood of receiving NRCCS was associated with patients' characteristics (97%): age, sub peritoneal rectal tumors, neoadjuvant therapy, residual tumour and stage III . There was no impact of European Deprivation Index or remoteness on NRRCS. Inter-health care structure variability was modest (3%), of which 50% was explained by the high group volume of colorectal procedures and the type of health care structure which were associated with less NRRCS (p<0.01)., Conclusion: There is an influence of operating volume and type of structure on the probability of NRRCS, but it has truly little importance in explaining differences in performances. The probability of NRRCS is mainly affected by clinical determinant., Competing Interests: Declaration of Competing Interest None declared, (Copyright © 2021. Published by Elsevier Ltd.)

Background: Retrospective studies suggest that watch-and-wait is a safe alternative to total mesorectal excision in selected patients with a clinical complete response after chemoradiotherapy., Objective: This study aimed to determine the proportion of patients with rectal cancer who may benefit from watch-and-wait., Design: This study is a retrospective analysis of data from prospectively maintained databases., Setting: This study was conducted at a comprehensive cancer center., Patients: Consecutive patients with stage II or III rectal adenocarcinoma who were treated with total neoadjuvant therapy using induction chemotherapy between 2012 and 2019 under the care of the same surgeon were included., Intervention: Induction-type total neoadjuvant therapy consisted of 8 cycles of leucovorin-fluorouracil-oxaliplatin or 5 cycles of capecitabine-oxaliplatin before chemoradiotherapy. Patients with a clinical complete response were offered watch-and-wait, and patients with residual tumor were offered total mesorectal excision., Main Outcomes and Measures: Tumor response was assessed with a digital rectal examination, endoscopy, and MRI. Patient characteristics and recurrence-free survival were compared between the watch-and-wait group and the total mesorectal excision group., Results: A total of 88 patients were included in the analysis. One (1%) died during neoadjuvant therapy. Fifty-five patients (62.5%) had an incomplete clinical response and underwent surgery, 10 (18%) of the 55 developed distant metastasis, and 3 (5%) developed local recurrence. The remaining 32 patients (36.3%) had a clinical complete response and underwent watch-and-wait. On average, patients in the watch-and-wait group were older and had smaller, more distal tumors compared with patients in the surgery group. The median radiation dose, number of chemotherapy cycles, rate of adverse events, and length of follow-up did not differ substantively between the total mesorectal excision group and the watch-and-wait group. In the watch-and-wait group, 2 (6%) patients developed tumor regrowth, and one of them had distant metastasis. Recurrence-free survival was significantly higher in the watch-and-wait group., Limitations: Generalizability, sample size, and follow-up duration were limitations of this study., Conclusions: Approximately one-third of patients with stage II or III rectal cancer can benefit from a watch-and-wait approach with the aim of preserving the rectum if treated with induction-type total neoadjuvant therapy and followed by an experienced multidisciplinary team. See Video Abstract at http://links.lww.com/DCR/B688., Conservacin De Rganos En Pacientes Con Cncer De Recto Tratados Con Terapia Neoadyuvante Total: ANTECEDENTES:Estudios retrospectivos sugieren que observar y esperar es una alternativa segura a la escisión mesorrectal total en pacientes seleccionados con una respuesta clínica completa después de la quimiorradioterapia.OBJETIVO:Determinar la proporción de pacientes con cáncer de recto que pueden beneficiarse de observar y esperar.DISEÑO:Análisis retrospectivo de datos de bases de datos mantenidas de forma prospectiva.ESCENARIO:Centro Oncológico Integral.PACIENTES:Pacientes consecutivos con adenocarcinoma de recto en estadio II o III tratados con TNT utilizando quimioterapia de inducción entre 2012 y 2019 bajo el cuidado del mismo cirujano.INTERVENCIÓN:La terapia neoadyuvante total de tipo inducción consistió en ocho ciclos de leucovorín-fluorouracilo-oxaliplatino o cinco ciclos de capecitabina-oxaliplatino antes de la quimiorradioterapia. A los pacientes con una respuesta clínica completa se les ofreció observar y esperar, y a los pacientes con tumor residual se les ofreció la escisión mesorrectal total.PRINCIPALES RESULTADOS Y MEDIDAS:La respuesta del tumor se evaluó con un tacto rectal, endoscopia y resonancia magnética. Se compararon las características de los pacientes y la supervivencia libre de recurrencia entre el grupo de observación y espera y el grupo de escisión mesorrectal total.RESULTADOS:Se incluyó en el análisis a un total de 88 pacientes. Uno (1%) murió durante la terapia neoadyuvante. Cincuenta y cinco pacientes (62.5%) tuvieron una respuesta clínica incompleta y se sometieron a cirugía; 10 (18%) de los 55 desarrollaron metástasis a distancia y 3 (5%) desarrollaron recidiva local. Los 32 pacientes restantes (36.3%) tuvieron una cCR (respuesta clínica completa) y se sometieron a observar y esperar. En promedio, los pacientes del grupo de observación y espera eran mayores y tenían tumores más pequeños y distales en comparación con el grupo de cirugía. La dosis mediana de radiación, el número de ciclos de quimioterapia, la tasa de eventos adversos y la duración del seguimiento no difirieron sustancialmente entre el grupo de escisión mesorrectal total y el grupo de observación y espera. En el grupo de observación y espera, 2 (6%) pacientes desarrollaron recrecimiento del tumor y uno de ellos tuvo metástasis a distancia. La supervivencia libre de recurrencia fue significativamente mayor en el grupo de observación y espera.LIMITACIONES:Generalizabilidad, tamaño de la muestra, duración del seguimiento.CONCLUSIONES:Aproximadamente un tercio de los pacientes con cáncer de recto en estadio II o III pueden beneficiarse de un abordaje de observación y espera con el objetivo de preservar el recto si se tratan con terapia neoadyuvante total de tipo inducción y son seguidos por un equipo multidisciplinario experimentado. Consulte Video Resumen en http://links.lww.com/DCR/B688., (Copyright © The ASCRS 2021.)

Objective: Obesity is known to be a preoperative risk factor for rectal cancer surgery. This study aimed to investigate the influence of obesity on the surgical outcomes of laparoscopic surgery for rectal cancer., Methods: The clinical data of 356 patients with rectal cancer from Jan 2012 to Dec 2015 were analyzed retrospectively. Perioperative outcomes were compared between 48 patients with a BMI (body mass index) ≥30 kg/m2 [obese group ] and 308 patients with a BMI≥30 kg/m2 [non-obese group] who underwent laparoscopic surgery., Results: Operation times were significantly longer for the obese group than for the non-obese group (125.2±30.5 min vs. 180.5±58.2 min, P=0.021). There were no statistically significant differences between two groups in terms of intraoperative blood loss, the number of retrieved lymph nodes, postoperative recovery and postoperative complications (P≥0.05). During the follow-up period, the overall survival rates were not significantly different between the two groups [66.7% (32/48) vs 67.2% (207/308), P=0.787]. The differences in recurrence and metastasis between the two groups were not statistically significant., Conclusion: Our analysis revealed that laparoscopic surgery can be safely performed in patients with BMI≥30. The procedure was considered to be difficult but sufficiently feasible.

Introduction: The ACS NSQIP Surgical Risk Calculator (SRC) assesses risk to support goal-concordant care. While it accurately predicts US outcomes, its performance internationally is unknown. This study evaluates SRC accuracy in predicting mortality following low anterior resection (LAR) and pancreaticoduodenectomy (PD) in NSQIP patients and accuracy retention when applied to native Japanese patients (National Clinical Database, NCD)., Methods: NSQIP (41,260 LAR; 15,114 PD) and NCD cases (61,220 LAR; 27,901 PD) from 2015 to 2017 were processed through the SRC mortality model. Country-specific calibration and discrimination were assessed with and without an intercept correction applied to the Japanese data., Results: The SRC exhibited acceptable calibration for LAR and PD when applied to NSQIP data but miscalibration for NCD data. A simple correction to the model intercept, motivated by lower mortality rates in the Japanese data, successfully remediated the miscalibration., Conclusions: The SRC may inaccurately predict surgical risk when applied to the native Japanese population. An intercept correction method is suggested when miscalibration is encountered; it is simple to implement and may permit effective international use of the SRC., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Little is known regarding the impact of hospital academic status on outcomes following rectal cancer surgery. We compare these outcomes for nonmetastatic rectal adenocarcinoma at academic versus community institutions., Methods: The National Cancer Database (2010-2016) was queried for patients with nonmetastatic rectal adenocarcinoma who underwent resection. Propensity score matching was performed across facility cohorts to balance confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival, other short and long-term outcomes were analyzed by way of logistic regression., Results: After matching, 15,096 patients were included per cohort. Academic centers were associated with significantly decreased odds of conversion and positive margins with significantly increased odds of ≥12 regional nodes examined. Academic programs also had decreased odds of 30 and 90-day mortality and decreased 5-year mortality hazard. After matching for facility volume, no significant differences in outcomes between centers was seen., Conclusions: No difference between academic and community centers in outcomes following surgery for non-metastatic rectal cancer was seen after matching for facility procedural volume., (Published by Elsevier Inc.)

Abstract: To determine the clinical and pathological outcome of locally advanced rectal cancer patients treated with neoadjuvant chemoradiation (chemoradiotherapy [CRT]) followed by curative surgery and to identify predictive factors of pathological complete response (pCR).Locally advanced rectal cancer patients undergoing CRT followed by curative surgery from January 2012 to December 2017 were included. Patient's demographic data, pretreatment tumor characteristics, type of CRT regimens, type of surgery, postoperative complications, pathological reports and follow up records were analyzed. Univariate and multivariate analyses were applied to identify predictive factors for pCR. Five-year disease free and overall survival were estimated by Kaplan-Meier method and compared between pCR and non-pCR groups.A total of 85 patients were analyzed. Eighteen patients (21.1%) achieved pCR. The sphincter-saving surgery rate was 57.6%. After univariate analyses, tumor length >4 cm (P = .007) and positive lymph nodes (P = .040) were significantly associated with decreased rate of pCR. Complete clinical response was significantly associated with higher rate of pCR (P = .015). Multivariate analyses demonstrated that tumor length >4 cm (P = .010) was significantly associated with decreased rate of pCR. After a median follow-up of 65 months (IQR 34-79), the calculated 5-year overall survival and disease-free survival rates were 81.4% and 69.7%, respectively. Patients who achieved pCR tend to had longer 5-year disease-free survival (P = .355) and overall survival (P = .361) than those who did not.Tumor length >4 cm was associated with decreased rate of pCR in locally advanced rectal cancer who had CRT followed by surgery. Longer waiting time or more intense adjuvant treatment may be considered to improved pCR and oncological outcomes., Competing Interests: The authors have no funding and no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Redo anastomosis can be considered in selected patients with persistent leakage, stenosis, or local recurrence. It is technically challenging, and little is known about the functional outcomes after this seldomly performed type of surgery., Objective: The aim of this study was to compare functional outcomes and the quality of life between redo anastomosis and primary successful anastomosis following total mesorectal excision for rectal cancer., Design: This study was designed as an international multicenter comparative cohort study., Settings: The study was conducted in 3 tertiary referral centers in the Netherlands, Belgium, and France., Patients: Patients undergoing redo anastomosis were compared with patients with a primary successful anastomosis after total mesorectal excision for rectal cancer., Main Outcome Measures: Low anterior resection syndrome score, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30, and EORTC QLQ-CR29 questionnaires were used to assess outcomes., Results: In total, 170 patients were included; 52 underwent redo anastomosis and 118 were controls. Major low anterior resection syndrome occurred in 73% after redo anastomosis compared with 68% following primary successful anastomosis (p = 0.52). The redo group had worse EORTC QLQ-CR29 mean scores for fecal incontinence (p = 0.03) and flatulence (p = 0.008). There were no differences in urinary (p = 0.48) or sexual dysfunction, either in men (p = 0.83) or in women (p = 0.76). Significantly worse scores in the redo group were found for global health (p = 0.002), role (p = 0.049) and social function (p = 0.006), body image (p = 0.03), and anxiety (p = 0.02)., Limitations: This study is limited by the possible response bias., Conclusions: Redo anastomosis is associated with significantly worse quality of life compared with primary successful anastomosis. However, major low anterior resection syndrome was comparable between groups and should not be a reason to preclude restoration of bowel continuity in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/B565., Resultados Funcionales Y De Calidad De Vida Posterior a La Reconstruccin De La Anastomosis En Pacientes Con Cncer De Recto Estudio Internacional Multicntrico De Cohorte Comparativo: ANTECEDENTES:Se puede considerar reconstruir la anastomosis en pacientes seleccionados con fuga persistente, estenosis o recidiva local. Esto es técnicamente desafiante y poco se sabe sobre los resultados funcionales después de este tipo de cirugía que rara vez se realiza.OBJETIVO:El objetivo de este estudio fue comparar resultados funcionales y la calidad de vida entre reconstrucción de la anastomosis y la anastomosis primaria exitosa posterior de la escisión total de mesorrecto (TME) por cáncer de recto.DISEÑO:Este estudio fue diseñado como un estudio internacional multicéntrico de cohorte comparativo.ENTORNO CLINICO:El estudio se llevó a cabo en tres centros de referencia terciarios en Holanda, Bélgica y Francia.PACIENTES:Los pacientes sometidos a reconstrucción de anastomosis fueron comparados con pacientes con anastomosis primaria exitosa después de TME por cáncer de recto.PRINCIPALES MEDIDAS DE VALORACION:Los cuestionarios; Escala de Síndrome de Resección Anterior Baja (LARS), EORTC QLQ-C30, y QLQ-CR29, fueron utilizados para evaluar los resultados.RESULTADOS:En total, se incluyeron 170 pacientes; 52 reconstrucción de anastomosis y 118 controles. LARS ocurrió en el 73% posterior a la reconstrucción de la anastomosis en comparación con el 68% posterior a la anastomosis primaria exitosa (p = 0,52). El grupo de reconstrucción tuvo peores puntuaciones medias de EORTC QLQ-CR29 para incontinencia fecal (p = 0,03) y flatulencia (p = 0,008). No hubo diferencias en disfunción urinaria (p = 0,48) o sexual, ni en hombres (p = 0,83) ni en mujeres (p = 0,76). Se encontraron puntuaciones significativamente peores en el grupo de reconstrucción para salud global (p = 0,002), desempeño (p = 0,049) y función social (p = 0,006), imagen corporal (p = 0,03) y ansiedad (p = 0,02).LIMITACIONES:La limitación de este estudio es el posible sesgo de respuesta.CONCLUSIONES:La reconstrucción de la anastomosis se asocia con una calidad de vida significativamente peor en comparación con los pacientes con anastomosis primaria exitosa. Sin embargo, LARS fue comparable entre los grupos y no debería ser una razón para impedir la restauración de la continuidad intestinal en pacientes muy motivados. Consulte Video Resumen en http://links.lww.com/DCR/B565., (Copyright © The ASCRS 2021.)

Background: Enhanced Recovery Programs (ERPs) benefit patients but their effects on healthcare costs remain unclear. This study aimed to investigate the costs associated with a colorectal ERP in a large academic health system., Methods: Patients who underwent colorectal surgery from 2012 to 2014 (pre-ERP) and 2015-2017 (ERP) were propensity score matched based on patient and operative-level characteristics. Primary outcomes were median variable, fixed, and total costs. Secondary outcomes included length-of-stay (LOS), readmissions, and postoperative complications (POCs)., Results: 616 surgical cases were included. Patient and operative-level characteristics were similar between the cohorts. Variable costs were $1028 less with ERP. ERP showed savings in nursing, surgery, anesthesiology, pharmacy, and laboratory costs, but had higher fixed costs. Total costs between the two groups were similar. ERP patients had significantly shorter LOS (-1 day, p < 0.01), but similar 30-day readmission rates and overall POCs., Conclusions: Implementation of an ERP for colorectal surgery was associated with lower variable costs compared to pre-ERP., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: TRICARE military beneficiaries are increasingly referred for major surgeries to civilian hospitals under "purchased care." This loss of volume may have a negative impact on the readiness of surgeons working in the "direct-care" setting at military treatment facilities and has important implications under the volume-quality paradigm. The objective of this study is to assess the impact of care source (direct versus purchased) and surgical volume on perioperative outcomes and costs of colorectal surgeries., Methods: We examined TRICARE claims and medical records for 18- to 64-year-old patients undergoing major colorectal surgery from 2006 to 2015. We used a retrospective, weighted estimating equations analysis to assess differences in 30-day outcomes (mortality, readmissions, and major or minor complications) and costs (index and total including 30-day postsurgery) for colorectal surgery patients between purchased and direct care., Results: We included 20,317 patients, with 24.8% undergoing direct-care surgery. Mean length of stay was 7.6 vs 7.7 days for direct and purchased care, respectively (P = .24). Adjusted 30-day odds between care settings revealed that although hospital readmissions (odds ratio 1.40) were significantly higher in direct care, overall complications (odds ratio 1.05) were similar between the 2 settings. However, mean total costs between direct and purchased care differed ($55,833 vs $30,513, respectively). Within direct care, mean total costs ($50,341; 95% confidence interval $41,509-$59,173) were lower at very high-volume facilities compared to other facilities ($54,869; 95% confidence interval $47,822-$61,916)., Conclusion: Direct care was associated with higher odds of readmissions, similar overall complications, and higher costs. Contrary to common assumptions regarding volume and quality, higher volume in the direct-care setting was not associated with fewer complications., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: In 2013 Swiss health authorities implemented annual hospital caseload requirements (CR) for five areas of visceral surgery. We assess the impact of the implementation of CR on indication for surgery in esophageal, pancreatic and rectal cancer., Materials and Methods: Retrospective analysis of national registry data of all inpatient admissions between January 1st , 2005 and December 31st , 2015. Primary end-point was the age-adjusted resection rate for esophageal, pancreatic and rectal cancer among patients with at least one cancer-specific hospitalization per year. We calculated age-adjusted rate ratios for period effects before and after implementation of CR and odds ratios (OR) based on a generalized estimation equation. A relative increase of 5% in age-adjusted relative risk was set a priori as relevant from a health policy perspective., Results: Age-adjusted resection rates before and after the implementation of CR were 0.12 and 0.13 (Relative Risk [RR] 1.08; 95%-Confidence Interval [CI] 0.85-1.36) in esophageal cancer, 0.22 and 0.26 (RR 1.17; 95%-CI 0.85-1.58) in pancreatic cancer and 0.38 and 0.43 (RR 1.14; 95%-CI 0.99-1.30) in rectal cancer. In adjusted models OR for resection after the implementation of CR were 1.40 (95%-CI 1.24-1.58) in esophageal cancer, 1.05 (95%-CI 0.96-1.15) in pancreatic cancer and 0.92 (95%-CI 0.87-0.97) in rectal cancer., Conclusion: Implementation of CR was associated with an increase of resection rates above the a priori set margins in all resections groups. In adjusted models, odds for resection were significantly higher for esophageal cancer, while they remained unchanged for pancreatic and decreased for rectal cancer., Competing Interests: Declaration of competing interest Elisabeth Deutschmann is an employee of F. Hoffmann-La Roche Ltd (includes Stock-Settled Appreciation Rights). The present study has no connection to her employment by the company. All other authors declare no conflicts of interest., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: In the setting of multidisciplinary standardized care of locally advanced rectal cancer, preoperative chemoradiotherapy and total mesorectal excision have become the mainstay treatment., Objective: This study aimed to evaluate whether the lack of preoperative chemoradiotherapy or poor response to it is associated with higher radial margin disease involvement in patients with locally advanced rectal cancer., Design: This is a retrospective cohort study using a publicly available database., Setting: Data were collected from the proctectomy-targeted National Surgical Quality Improvement Project file from 2016 to 2017., Patients: A total of 1161 patients were analyzed. They were categorized into 3 groups: patients who did not receive any preoperative chemoradiotherapy (28.6%), patients who received and responded to preoperative chemoradiotherapy (41.2%), and patients who received but did not respond to preoperative chemoradiotherapy (30.2%)., Main Outcome Measures: Response to treatment was determined by using the American Joint Committee on Cancer pretreatment and final pathological staging. Circumferential radial margin was extracted from the targeted proctectomy file., Results: Disease-involved positive circumferential radial margin was found in 86 (7.4%) cases. Positive radial margin was noted in 11 of 479 patients (2.3%) who underwent preoperative chemoradiotherapy and responded to treatment, 30 of 350 patients (8.6%) who did not respond or had a poor response to preoperative chemoradiotherapy, and 45 of 332 patients (13.6%) who did not receive preoperative chemoradiotherapy (p < 0.001). Regression analysis demonstrated that patients who do not receive preoperative chemoradiotherapy or have poor response to it have 6.6 and 4 times higher chances of having a positive radial margin., Limitations: There is a risk of selection bias, unidentified confounders, and missing data despite the use of a nationwide cohort., Conclusions: Omission of indicated preoperative chemoradiotherapy or poor response to it is associated with increased risk of radial margin positivity. More efforts are needed for standardized rectal cancer care with the appropriate use of preoperative chemoradiotherapy. See Video Abstract at http://links.lww.com/DCR/B467., La Omisin O La Escasa Respuesta a Quimioradioterapia Preoperatoria, Afecta Las Tasas De Positividad Del Margen Radial, En El Cncer Rectal Localmente Avanzado: ANTECEDENTES:En el contexto de la atención multidisciplinaria estandarizada del cáncer rectal localmente avanzado, la quimioradioterapia preoperatoria y la escisión mesorrectal total, se han convertido en el tratamiento principal.OBJETIVO:Evaluar si la omisión de quimioradioterapia preoperatoria o la escasa respuesta, se asocia con mayor enfermedad del margen radial, en pacientes con cáncer rectal localmente avanzado.DISEÑO:Estudio de cohorte retrospectivo utilizando una base de datos disponible públicamente.AJUSTE:Se recopilaron datos del archivo del Proyecto Nacional de Mejora de la Calidad Quirúrgica dirigido a la proctectomía de 2016-2017.PACIENTES:Se analizaron un total de 1161 pacientes. Clasificados en tres grupos: pacientes que no recibieron quimioradioterapia preoperatoria (28,6%), pacientes que recibieron y respondieron a quimioradioterapia preoperatoria (41,2%) y pacientes que recibieron pero no respondieron a la quimioradioterapia preoperatoria (30,2%).PRINCIPALES MEDIDAS DE RESULTADO:La respuesta al tratamiento se determinó utilizando el pre tratamiento y la estatificación patológica final, del American Joint Committee on Cancer. El margen radial circunferencial se extrajo del archivo de proctectomía dirigida.RESULTADOS:Se encontró enfermedad que abarcaba el margen radial circunferencial +, en el 86 (7,4%) casos. Se observó el margen radial +, en 11 de 479 pacientes (2,3%) que se sometieron a quimioradioterapia preoperatoria y respondieron al tratamiento, 30 de 350 pacientes (8,6%) que no respondieron o tuvieron una mala respuesta con quimioradioterapia preoperatoria y en 45 de 332 pacientes (13,6%) que no recibieron quimioradioterapia preoperatoria (p <0,001). El análisis de regresión demostró que los pacientes que no reciben quimioradioterapia preoperatoria o que tienen escasa respuesta, presentan respectivamente, 6,6 y 4 veces más probabilidades de tener un margen radial +.LIMITACIONES:Existe el riesgo de sesgo de selección, factores de confusión no identificados y datos faltantes a pesar del uso de una cohorte nacional.CONCLUSIONES:La omisión de la quimioradioterapia preoperatoria indicada o la escasa respuesta, se asocian a un mayor riesgo de positividad del margen radial. Se necesitan mayores esfuerzos en la atención estandarizada del cáncer rectal, con el uso adecuado de quimioradioterapia preoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B467., (Copyright © The ASCRS 2021.)

Background: Ever since transanal total mesorectal excision was introduced by Sylla and Lacy in 2010, it has become more popular among colorectal surgeons. However, some surgeons hesitate to use it, because this novel approach differs greatly from laparoscopic total mesorectal excision and requires a long learning curve., Objective: This study analyzed the learning curve of transanal total mesorectal excision procedure and compared the different phases of transanal total mesorectal excision with laparoscopic total mesorectal excision., Design: This is retrospective case-control study., Settings: We used data from the approved colorectal cancer database of the Sixth Affiliated Hospital of Sun Yat-sen University., Patients: The patients involved in this study underwent transanal total mesorectal excision performed by a single surgeon (L.K.) or underwent laparoscopic transanal total mesorectal excision performed by experienced surgeons., Interventions: Transanal or laparoscopic resection of mid-low rectal cancer was conducted., Main Outcomes Measures: Perioperative complication and resection margin were measured., Results: A total of 342 patients were included in both groups. The learning curve of transanal total mesorectal excision was divided into 3 phases. Data show that demographics and tumor characteristics were not significantly different between the matched groups. Indeed, during phase 1, only operative time was longer than in the laparoscopic group, whereas, during phase 2, results from the transanal group were comparable with the laparoscopic group. Results show that, during phase 3, operative time, intraoperative blood loss, and postoperative hospital stay were all lower than in the laparoscopic group. Local recurrence occurred in 3 patients during phase 1 and in 1 patient during phase 2., Limitations: This study was a small retrospective study and focused on just 1 surgeon performing transanal total mesorectal excision., Conclusions: Short-term and histopathologic outcomes are similar compared between a transanal group and matched laparoscopic group. Transanal total mesorectal excision also provided good oncologic outcomes. See Video Abstract at http://links.lww.com/DCR/B450., Escisin Mesorrectal Total Transanal En El Cncer De Recto Mediobajo Evaluacin De La Curva De Aprendizaje Y Comparacin De Resultados a Corto Plazo Con Tme Laparoscpica Estndar: ANTECEDENTES:Desde que Sylla y Lacy introdujeron la escisión mesorrectal total transanal en 2010, se ha vuelto más popular entre los cirujanos colorrectales. Sin embargo, algunos cirujanos dudan en utilizarlo, porque este nuevo método difiere mucho de la escisión mesorrectal total laparoscópica y requiere una larga curva de aprendizaje.OBJETIVO:Este estudio analizó la curva de aprendizaje del procedimiento de escisión mesorrectal total transanal y comparó las diferentes fases de la escisión mesorrectal total transanal con la escisión mesorrectal total laparoscópica.DISEÑO:Este es un estudio retrospectivo de casos y controles.ENTORNO CLINICO:Utilizamos base de datos de cáncer colorrectal aprobada del Sexto Hospital Afiliado de la Universidad Sun Yat-sen (Guangzhou, China).PACIENTES:Los pacientes involucrados en este estudio fueron sometidos a escisión mesorrectal total transanal realizada por un solo cirujano (LK) o se sometieron a escisión mesorrectal total transanal laparoscópica realizada por cirujanos experimentados.INTERVENCIONES:Resección transanal o laparoscópica de cáncer de recto medio-bajo.PRINCIPALES MEDIDAS DE VOLARCION:complicación perioperatoria y margen de resección.RESULTADOS:Se incluyó un total de 342 pacientes en ambos grupos. La curva de aprendizaje de la escisión mesorrectal total transanal se dividió en tres fases. Los datos muestran que las características demográficas y tumorales no fueron significativamente diferentes entre los grupos emparejados. De hecho, durante la fase 1, solo el tiempo operatorio fue más largo que en el grupo laparoscópico. Mientras que durante la fase 2, los resultados del grupo transanal fueron comparables a los del grupo laparoscópico. Los resultados muestran que durante la fase 3, el tiempo operatorio, la pérdida de sangre intraoperatoria y la estancia hospitalaria postoperatoria fueron menores que en el grupo laparoscópico. La recurrencia local ocurrió en 3 pacientes durante la fase 1 y en 1 paciente durante la fase 2.LIMITACIONES:Este estudio fue un estudio retrospectivo pequeño y se centró en un solo cirujano que realizaba la escisión mesorrectal total transanal.CONCLUSIÓN:Los resultados a corto plazo e histopatológicos son similares en comparación entre el grupo transanal y el grupo laparoscópico emparejado. La escisión mesorrectal total transanal también proporcionó buenos resultados oncológicos. Consulte Video Resumen en http://links.lww.com/DCR/B450., Competing Interests: Financial Disclosure: The authors declare that they have no conflict of interest., (Copyright © The ASCRS 2021.)

Background: A more extensive resection is often required in locally advanced rectal cancer, depending on preoperative neoadjuvant treatment response., Objective: Circumferential margin involvement and postoperative outcomes after total mesorectal excision and multivisceral resection were assessed in patients with clinical locally advanced (cT4) rectal cancer at a national level., Design: This is a population-based study., Settings: Data were retrieved from the Dutch Colorectal Audit., Patients: A total of 2242 of 2881 patients with cT4 rectal cancer between January 2009 and December 2017 were selected., Main Outcome Measures: Main outcomes were resection margins, postoperative complications, and mortality., Results: Multivisceral resection was performed in 936 of 2242 patients, of whom 629 underwent extended multivisceral resection. Positive circumferential margin rate was higher after multivisceral resection than after total mesorectal excision: 21.2% vs 13.9% (p < 0.001). More postoperative complications occurred after limited and extended multivisceral resections than after total mesorectal excision (44.1% and 53.8% vs 37.6%, p < 0.001). Incidence of 30-day mortality was similarly low in both groups (1.5% vs 2.2%, p = 0.20). Independent predictors of postoperative complications were age ≥70 years (OR, 1.28 [95% CI, 1.04-1.56]; p = 0.02), male sex (OR, 1.68 [95% CI, 1.38-2.04]; p< 0.001), mucinous tumors (OR, 1.55 [95% CI, 1.06-2.27]; p = 0.02), extended multivisceral resection (OR, 1.98 [95% CI, 1.56-2.52]; p< 0.001), Hartmann procedure (OR, 1.42 [95% CI, 1.07-1.90]; p = 0.02), and abdominoperineal resection (OR, 1.56 [95% CI, 1.25-1.96]; p < 0.001)., Limitations: Data specifying the extent of multivisceral resections and Clavien Dindo I to II complications were not available., Conclusions: This population-based study revealed relatively high circumferential margin positivity and postoperative complication rates in patients with cT4 rectal cancer, especially after multivisceral resections, but low mortality rates. See Video Abstract at http://links.lww.com/DCR/B457., Alta Tasa Persistente De Mrgenes Positivos Y Complicaciones Postoperatorias Despus De La Ciruga De Cncer Rectal Cta Nivel Nacional: ANTECEDENTES:A menudo se requiere una resección más extensa en el cáncer de recto localmente avanzado, según la respuesta al tratamiento neoadyuvante preoperatorio.OBJETIVO:Se evaluó la afectación del margen circunferencial y los resultados postoperatorios después de la escisión mesorrectal total y la resección multivisceral en pacientes con cáncer rectal clínico localmente avanzado (cT4) a nivel nacional.DISEÑO:Este es un estudio poblacional.ENTORNO CLINICO:Los datos se recuperaron de la Auditoría colorrectal holandesa.PACIENTES:Se seleccionaron un total de 2242 de 2881 pacientes con cáncer de recto cT4 entre enero de 2009 y diciembre de 2017.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron los márgenes de resección, las complicaciones postoperatorias y la mortalidad.RESULTADOS:Se realizó resección multivisceral en 936 de 2242 pacientes, de los cuales 629 fueron sometidos a resección multivisceral extendida. La tasa de margen circunferencial positivo fue mayor después de la resección multivisceral que después de la escisión mesorrectal total: 21,2% versus a 13,9% (p <0,001). Se produjeron más complicaciones postoperatorias después de resecciones multiviscerales limitadas y extendidas en comparación con la escisión mesorrectal total (44,1% y 53,8% versus a 37,6%, p <0,001). La incidencia de mortalidad a 30 días fue igualmente baja en ambos grupos (1,5% versus a 2,2%, p = 0,20). Los predictores independientes de complicaciones posoperatorias fueron la edad ≥70 años (OR = 1,28, IC del 95% [1,04 a 1,56], p = 0,02), hombres (OR = 1,68, IC del 95% [1,38 a 2,04], p <0,001), tumores mucinosos (OR = 1,55, IC del 95% [1,06 a 2,27], p = 0,02), resección multivisceral extendida (OR = 1,98, IC del 95% [1,56 a 2,52], p <0,001), Hartmann (OR = 1,42, 95% Cl [1,07 a 1,90], p = 0,02) y resección abdominoperineal (OR 1,56, Cl 95% [1,25 a 1,96], p <0,001).LIMITACIONES:No se disponía de datos que especificaran el alcance de las resecciones multiviscerales y las complicaciones de Clavien Dindo I-II.CONCLUSIONES:Este estudio poblacional reveló tasas de complicaciones postoperatorias y positividad del margen circunferencial relativamente altas en pacientes con cáncer de recto cT4, especialmente después de resecciones multiviscerales, pero tasas de mortalidad bajas. Consulte Video Resumen en http://links.lww.com/DCR/B457., (Copyright © The ASCRS 2021.)

Background: Extranodal extension (ENE) of nodal metastasis has emerged as an important prognostic factor in many malignancies, including rectal cancer. However, its significance in patients with rectal cancer receiving preoperative chemoradiotherapy (PCRT) has not been extensively investigated. We therefore assessed ENE and its prognostic impact in a large series of consecutive rectal cancer patients with lymph node metastasis after PCRT and curative resection., Patients and Methods: Between January 2000 and December 2014, a total of 1925 patients with rectal cancer underwent surgical resection after PCRT. Medical records of 469 patients with pathologic node positivity were retrospectively reviewed., Results: Of the 469 patients, 118 (25.2%) presented with ENE. ENE was observed more frequently in those with advanced tumor stage (higher ypT, ypN, and ypStage), lymphovascular invasion, and perineural invasion. Five-year disease-free survival rate was lower in patients with ENE-positive tumors than those with ENE-negative tumors (36.1% vs. 52.3%, P = .003). Similarly, 5-year overall survival rate was lower in patients with ENE-positive tumors than those with ENE-negative tumors (60.2% vs. 70.6%, P < .001). Multivariate analysis revealed that the presence of ENE was an independent poor prognostic factor for disease-free survival (hazard ratio = 1.412; 95% confidence interval, 1.074-1.857; P = .013) and overall survival (hazard ratio = 1.531; 95% confidence interval 1.149-2.039; P = .004)., Conclusion: The presence of ENE in patients with rectal cancer undergoing PCRT is a negative prognostic factor, reflecting poor survival outcome., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes., Methods: A cross-sectional questionnaire was administered to surgeons and nurses in August-October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013-15., Results: 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management., Conclusions: Standardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.

Background: Small bowel obstruction (SBO) is observed in around 10% of patients with prior open abdominal surgery. Rectal resection causes the highest readmission rates. The aim of this study was to investigate risk factors for readmission for SBO and causes for SBO in patients who needed surgery following rectal cancer surgery., Methods: A population-based registry with prospectively gathered data on 752 consecutive patients with rectal cancer who underwent open pelvic surgery between January 1996 and January 2017 was used. Univariable and multivariable regression analysis was performed, and the risk of SBO was assessed., Results: In total, 84 patients (11%) developed SBO after a median follow-up time of 48 months. Of these patients, 57% developed SBO during the 1st year after rectal cancer surgery. Surgery for SBO was performed in 32 patients (4.3%), and the cause of SBO was stoma-related in one-fourth of these patients. In the univariable analysis previous RT and re-laparotomy were found as risk factors for readmission for SBO. Re-laparotomy was an independent risk factor for readmission for SBO (OR 2.824, CI 1.129-7.065, P = 0.026) in the multivariable analysis, but not for surgery for SBO. Rectal resection without anastomoses, splenic flexors mobilization, intraoperative bleeding, operative time were not found as risk factors for SBO., Conclusions: One-tenth of rectal cancer patients who had open surgery developed SBO, most commonly within the 1st postoperative year. The risk of SBO is greatest in patients with complications after rectal cancer resection that result in a re-laparotomy.

Background: When, whether, and in whom primary tumor resection (PTR) for patients with metastatic colorectal cancer (CRC) is indicated remains unknown. With advances in multiagent systemic chemotherapy, PTR may be undertaken less frequently. The aim of this study was to obtain estimates of changes in the utilization of PTR and chemotherapy for metastatic CRC., Methods: Patients diagnosed with metastatic CRC between 2000 and 2016 were identified from Surveillance Epidemiology, and End Results (SEER) registry. Multivariable logistic regression defined odds of undergoing PTR. The analysis was also stratified by primary site (colon vs. rectum), age (younger than 50 vs. 50 y and older), and whether patients also underwent resection of metastatic sites (yes vs. no). The secondary endpoint of interest was the receipt of any chemotherapy, also assessed by multivariable logistic regression., Results: Among 99,835 patients with metastatic CRC, 55,527 (55.7%) underwent PTR. The odds of undergoing PTR decreased with a later year of diagnosis, with patients diagnosed in 2016 being 61.1% less likely to undergo surgery than those diagnosed in 2000 (adjusted odds ratio=0.39, 95% confidence interval: 0.36-0.42, P<0.0001; absolute percentage: 62.3% to 43.8%). Similar trends by year for PTR were observed among each of the subgroups, although patients with colon primary, young adults (age younger than 50 y), and patients also undergoing metastasectomy were more likely to undergo PTR (P<0.001 for all). In contrast, the odds of receiving chemotherapy increased dramatically with a later year of diagnosis (adjusted odds ratio=2.21, 95% confidence interval: 2.04-2.40, P<0.0001)., Conclusions: From 2000 to 2016, there was a sharp decline in the rate of PTR for patients with metastatic CRC, while the use of chemotherapy increased over the same period. Prospective studies are needed to define the optimal local treatment for patients with metastatic CRC., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Chemoradiotherapy (CRT) followed by surgery is the recommended approach in the last years for stage II and III rectal cancer with the intention to decrease the risk of local recurrence. However, fewer patients benefit from this strategy in terms of overall survival and long-term adverse outcomes because T3 rectal cancer has a broad range of prognosis, as shown by recent publications. Many patients with cT3 rectal cancer have a substantial risk of overtreatment with long-term toxicity related to radiotherapy that could be avoided in a subset group of cT3 tumors with good prognosis. These findings raised the question of whether all cT3 rectal cancer should receive preoperative radiotherapy and if a selected cT3 subgroup could be treated by surgery alone. This review addresses the rationale of selecting good prognosis cT3 rectal cancer for surgery alone and analyzes the data to support this recommendation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Tumour extension beyond the mesorectal plane (ymrT4) occurs in 5-10 per cent of patients with rectal cancer and 10 per cent of patients develop locally recurrent rectal cancer (LRRC) after primary surgery. There is global variation in healthcare delivery for these conditions., Methods: An international benchmark trial of the management of ymrT4 tumours and LRRC was undertaken in France and Australia between 2015 and 2017. Heterogeneity in management and operative decision-making were analysed by comparison of surgical resection rates, blinded intercountry reading of pelvic MRI, quality-of-life assessment and qualitative evaluations., Results: Among 154 patients (97 in France and 57 in Australia), 31·8 per cent had ymrT4 disease and 68·2 per cent LRRC. The surgical resection rates were 88 and 79 per cent in France and Australia respectively (P = 0·112). The concordance in operative planning was low (κ = 0·314); the rate of pelvic exenteration was lower in France than Australia both in clinical practice (36 of 78 versus 34 of 40; P < 0·001) and in theoretical conditions (10 of 25 versus 50 of 57; P = 0·002). The R0 resection rate was lower in France than Australia for LRRC (25 of 49 versus 18 of 21; P = 0·007) but not for ymrT4 tumours (21 of 26 versus 15 of 15; P = 0·139). Morbidity rates were similar. Patients who underwent non-exenterative procedures had higher scores on the mental functioning subscale at 12 months (P = 0·047), and a lower level of distress at 6 months (P = 0·049). Qualitative analysis highlighted five categories of psychosocial factors influencing treatment decisions: patient, strategy, specialist, organization and culture., Conclusion: This international benchmark trial has highlighted the differences in worldwide treatment of locally advanced and LRRC. Standardized care should improve outcomes for these patients., (© 2020 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Background: Anal SCC is a rare disease mainly treated with chemoradiation. Abdominoperineal resection (APR), once the mainstay of treatment for anal cancer, now serves a role as salvage therapy for persistent or recurrent disease after chemoradiation. In addition, clinically positive nodes are currently treated by extending the radiation field to the groin. The role of inguinal lymph node dissection in recurrent or persistent anal SCC is unclear. The aim of the study is to determine the role of inguinal lymph node dissection in the management of inguinal lymph node metastasis for anal squamous cell carcinoma (SCC)., Methods: Retrospective analysis of patients with anal SCC in the National Cancer Database with positive inguinal nodes undergoing salvage APR between 2004 and 2014 was performed. A comparison of overall survival between patients who underwent APR with lymph node dissection versus APR only was analyzed using Kaplan-Meier plot., Results: A total of 3424 patients underwent salvage APR, with 274 (8%) having clinically positive nodes. Within the subgroup that had clinically positive nodes, 195 (71%) underwent APR, whereas 79 (29%) underwent both APR and node dissection. Kaplan-Meier analysis demonstrates no difference in overall survival in the two groups (P = 0.99). Five-year survival for both groups was similar (36% versus 42%; P = 0.987). No significant difference was found when adjusted for age, gender, and Tumor Node Metastasis staging., Conclusions: Inguinal lymph node dissection does not appear to improve overall survival in patients with advanced-stage anal cancer requiring salvage APR. Proper patient selection for node dissection is essential to spare patients from additional morbid procedures., (Published by Elsevier Inc.)

Background: The robotic platform is increasingly used in colorectal surgery. Recent upgrades in the robotic platform and introduction of proctectomy-specific reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) warrant updated evaluation of minimally invasive proctectomy outcomes. The aim of this study was to compare outcomes in robotic versus laparoscopic proctectomy using ACS-NSQIP data., Materials and Methods: The ACS-NSQIP data set was used to identify adult patients undergoing elective robotic and laparoscopic proctectomy in 2016 and 2017. Demographics, preoperative and intraoperative data, and postoperative outcomes were collected. Propensity-weighted analysis was used to estimate the effect of robotic versus laparoscopic surgery on outcomes., Results: Of 3845 patients meeting inclusion criteria, 2681 (70%) underwent a laparoscopic approach and 1164 (30%) underwent a robotic approach. Patients undergoing a robotic procedure were more likely to be older, have higher American Society of Anesthesiologists scores, low rectal tumors, and have undergone chemotherapy or radiation before surgery. After propensity adjustment, a robotic approach was associated with a decrease in conversion to open operation (estimated mean difference, -6.7%; P < 0.01), length of stay (-0.6 d; P = 0.01), occurrence of postoperative ileus (-3.7%; P = 0.01), and an increase in operative time (20.3 min; P < 0.01)., Conclusions: Using data from a national cohort, we found that compared with laparoscopy, robotic proctectomy is associated with decreased conversion to open operation, longer operation time, decreased length of stay, and decreased postoperative ileus. Our study identified several advantages to a robotic approach; however, further work is needed to assess cost-effectiveness in conjunction with clinical outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: The coronavirus disease 2019 (COVID-19) pandemic hit Italy early and strongly, challenging the whole health care system. Proctological patients and surgeons are experiencing a previously unseen change in care with unknown repercussion. Here we discuss the proctological experience of 4 Italian hospitals during the COVID-19 pandemic., Methods: Following remote brainstorming, the authors summarised their experience in managing proctological patients during the COVID-19 pandemics and put forward some practical observations to further investigate., Results: The 4 hospitals shifted from a high-volume proctological activity to almost "zero" visits and surgery. Every patient accessing the hospital must respect a specific COVID-19 protocol. Proctological patients can be stratified based on presentation and management considerations into (1) neoplastic patients, the only allowed to be surgically treated, (2) the ones requiring urgent care, operated only in highly selected cases and (3) the stable, already known patients, managed remotely. Changes in the clinical management of the proctological disease are presented together with some considerations to be explored., Conclusions: In the absence of scientific evidence, these practical considerations may be valuable to proctological surgeons starting to face the COVID-19 pandemics. Beside the more clinical considerations, this crisis produced unexpected consequences such as an improvement of the therapeutic alliance and a shift towards telemedicine that may be worth exploring also in the post-COVID-19 era.

Background: Anal adenocarcinoma (AA) is reported to represent 5% to 10% of all anal cancer. Currently there is no evidence-based treatment of AA. We investigated clinical outcomes after treatment regimens in patients with AA and used the Surveillance, Epidemiology, and End Results (SEER) registry to examine the outcome., Patients and Methods: We searched for patients diagnosed with histologically confirmed adenocarcinoma of the anal canal with stage I to III disease between 2010 and 2016 using SEER∗Stat software., Results: A total of 393 patients treated from 2010 to 2016 for AA were identified. Patients were divided into 5 groups according to treatment: 68 patients (17.3%) receiving radiotherapy (RT) and chemotherapy (CTx), 16 patients (4.1%) receiving RT or CTx, 108 patients (27.5%) receiving surgery alone, 137 patients (34.8%) receiving preoperative RT or CTx with surgery, and 64 patients (16.3%) receiving postoperative RT or CTx with surgery. The 3-year cause-specific survival (CSS) rates were 63.9% in the RT and CTx group, 35.7% in the RT or CTx group, 77.7% in the surgery-alone group, 80.3% in the preoperative RT or CTx group, and 65.8% in the postoperative group (P < .001). Preoperative RT or CTx was associated with improved CSS on multivariate analysis (P = .024). The 3-year CSS rates for those who received surgery and those who did not receive surgery were 81.5% and 87.5% for stage I disease, and 74.4% and 57.3% for stage II/III disease., Conclusion: Preoperative treatment with surgical resection may maximize the survival outcome. Although chemoradiotherapy alone may be sufficient for early stages of disease, patients with advanced disease should be treated with a combination of surgical resection and chemoradiotherapy. Future studies are required to determine the appropriate treatment strategies in AA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: National Comprehensive Cancer Network guidelines for the treatment of locally advanced rectal cancer advocate neoadjuvant chemoradiotherapy followed by total mesorectal excision and adjuvant chemotherapy (AC). The aim of this retrospective study was to determine our local patterns of AC use and to examine factors that influenced initiation and completion of AC among patients with stage II/III rectal cancer., Patients and Methods: The study population consisted of stage II/III rectal cancer patients who were treated at the University of Rochester from 2011 to 2014. Chart reviews were conducted to determine rates of AC initiation and completion. The documented reasons for failure to initiate or complete AC were examined. A multivariate analysis was also completed to evaluate factors that may have influenced the initiation and use of AC., Results: Eighty-one patients were included in the analysis. Median age was 62 years, and 53 (65.4%) were male. Median time from surgery to initiation of AC in those who received AC was 8.0 weeks. Forty-seven patients (58.0%) completed their prescribed AC course. Twenty-four patients (29.6%) did not start AC and 9 patients (11.1%) were unable to complete their course of AC. Primary reasons for not undergoing AC were patient preference (37.5%) and prolonged surgical recovery (33.3%). Primary reasons for not completing AC were treatment toxicities (55.5%) and patient preference (22.2%). Multivariate analysis identified a positive association between clinical stage III disease at diagnosis and initiation of AC. There was no independent association between pathologic response to neoadjuvant therapy at time of surgery and receipt of AC., Conclusion: A large proportion of patients at a single academic center did not start or complete their prescribed postoperative AC for locally advanced rectal cancer. Ongoing studies are investigating a total neoadjuvant approach, which may result in better chemotherapy adherence and further improve the pathologic downstaging rate., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Few studies have examined gender differences in the clinical management of rectal cancer. We examine differences in stage at diagnosis and preoperative radiotherapy in rectal cancer patients., Methods: A prospective cohort study was conducted in 22 hospitals in Spain including 770 patients undergoing surgery for rectal cancer. Study outcomes were disseminated disease at diagnosis and receiving preoperative radiotherapy. Age, comorbidity, referral from a screening program, diagnostic delay, distance from the anal verge, and tumor depth were considered as factors that might explain gender differences in these outcomes., Results: Women were more likely to be diagnosed with disseminated disease among those referred from screening (odds ratio, confidence interval 95% (OR, CI = 7.2, 0.9-55.8) and among those with a diagnostic delay greater than 3 months (OR, CI = 5.1, 1.2-21.6). Women were less likely to receive preoperative radiotherapy if they were younger than 65 years of age (OR, CI = 0.6, 0.3-1.0) and if their tumors were cT3 or cT4 (OR, CI = 0.5, 0.4-0.7)., Conclusions: The gender-specific sensitivity of rectal cancer screening tests, gender differences in referrals and clinical reasons for not prescribing preoperative radiotherapy in women should be further examined. If these gender differences are not clinically justifiable, their elimination might enhance survival.

Background: Patients with rectal cancer who achieve complete clinical response after neoadjuvant chemoradiation have been managed nonoperatively. Thirty percent of these patients may develop a local regrowth, and salvage resection with radical surgery is usually recommended. However, selected patients could be offered additional organ preservation by local excision. We hypothesized that patients with baseline T2 who underwent neoadjuvant therapy (for the specific purpose of achieving a complete clinical response) were more likely to harbor recurrent disease at an earlier stage and amenable to organ preservation strategies (local excision) when compared with T3/T4 (undergoing neoadjuvant chemoradiation for oncologic reasons)., Objective: The purpose of this study was to compare patients with local regrowth requiring salvage resection according to their baseline stage., Design: This was a retrospective review of consecutive patients with nonmetastatic distal rectal cancer undergoing neoadjuvant chemoradiation., Settings: The study included 2 independent tertiary centers with institutional watch-and-wait organ preservation programs., Patients: Consecutive patients with distal rectal cancer (cT2-4N1-2M0) managed by watch and wait and local regrowth from 2 institutions were included., Main Outcomes Measures: Final pathologic features and surgical and oncologic outcomes were compared according to baseline staging., Results: A total of 73 of 257 patients experienced local regrowth. cT2 presented similar to ypT, ypN, R0, and abdominal perineal resection rates (p > 0.05) at the time of salvage when compared with cT3 to cT4. Patients with cT2 at baseline were more likely to undergo an organ preservation procedure for salvage (56.2% vs 26.5%; p = 0.03). Overall and disease-free survival after salvage were similar between groups irrespective of the type of surgery for the regrowth., Limitations: Retrospective study, small sample size, and possible inaccurate baseline staging., Conclusions: Although patients with baseline cT2 rectal cancer had similar pathologic stage at the time of recurrence, these patients were more likely to continue an organ preservation pathway after local regrowth through transanal local excision when compared with cT3 to cT4. Despite differences in the use of radical salvage resection, there were no differences in oncologic outcomes. See Video Abstract at http://links.lww.com/DCR/B254. CIRUGÍA DE RESCATE CON PRESERVACIÓN DE ORGANO PARA PACIENTES CON RECIDIVA LOCAL LUEGO DE WATCH & WAIT: ¿SIGUE SIENDO POSIBLE?: Los pacientes con cáncer rectal que logran una respuesta clínica completa luego de la quimiorradiación neoadyuvante han sido tratados de forma no quirúrgica. El treinta por ciento de estos pacientes pueden desarrollar un nuevo crecimiento local y generalmente se recomienda la resección de rescate con cirugía radical. Sin embargo, en pacientes seleccionados se podría ofrecer la posibilidad de preservación de órgano mediante escisión local. Se formuló la hipótesis de que los pacientes con estadio clinico inicial T2 y sometidos a terapia neoadyuvante (con el propósito específico de lograr una respuesta clínica completa) tenían más probabilidades de presentar una recurrencia local en una etapa más temprana y suceptibles de estrategias de preservación de órgano (escisión local) en comparación con T3 / T4 (sometidos a nCRT por razones oncológicas).Comparar los pacientes con recidiva local que requirieron cirugia de rescate de acuerdo con su estadio inicial.Revisión retrospectiva de pacientes consecutivos con cáncer de recto distal no metastásico sometidos a quimiorradiación neoadyuvante.Dos centros terciarios independientes con programas institucionales de preservación de órgano - Watch & Wait.Pacientes consecutivos con cáncer rectal distal (cT2-4N1-2M0) manejados por Watch & Wait y recidiva local.Las características patológicas finales, los resultados quirúrgicos y oncológicos se compararon de acuerdo con la estadificación inicial.Un total de 73 de 257 pacientes presentaron recidiva local. cT2 presentaron similares ypT, ypN, R0 y tasas de resección abdominoperineal (p>0,05) en el momento del rescate en comparación con cT3-4.Los pacientes con cT2 de base tuvieron más probabilidades de someterse a un procedimiento de preservación de órgano durante el rescate (56,2% frente a 26,5%; p = 0,03). Supervivencia general y DFS después del rescate fueron similares entre los grupos, independientemente del tipo de cirugía para la recidiva.Estudio retrospectivo, tamaño de muestra pequeño, la posible estadificación basal inexacta.Aunque los pacientes con cáncer rectal cT2 de base presentaron estadio patologico similar en el momento de la recidiva, estos pacientes tuvieron más probabilidades de continuar una vía de preservación de órgano luego de una recidiva local a través de la escisión local transanal en comparación con cT3-4. A pesar de las diferencias en el uso de la resección radical de rescate, no hubo diferencias en los resultados oncológicos. Consulte Video Resumen en http://links.lww.com/DCR/B254.

Introduction: Synoptic operative reporting has been shown to improve completeness and consistency in surgical documentation. We sought to determine whether operative reports contain the key elements recommended by the National Accreditation Program for Rectal Cancer., Methods: Rectal cancer operative reports from June-December 2018 were submitted from ten hospitals in Michigan. These reports were analyzed to identify key elements in the synoptic operative template and assessed for completeness., Results: In total, 110 operative reports were reviewed. Thirty-one (28%) reports contained all 24 elements; all of these reports used a synoptic template. Overall, 62 (56%) reports used a synoptic template and 48 (44%) did not. Using a synoptic template significantly improved documentation, as these reports contained 92% of required elements, compared to 39% for narrative reports (p < 0.001)., Conclusions/discussion: Narrative operative reports inconsistently document rectal cancer resection. This study provides evidence that synoptic reporting will improve quality of documentation for rectal cancer surgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: There is no clear consensus on the use of re-irradiation (reRT) in the management of locally recurrent rectal cancer (LRRC). The aim of the present study was to investigate all reRT administered for rectal cancer at a large referral institution and to evaluate patient outcomes and toxicity. Material and methods: All patients with rectal cancer were identified who had received previous pelvic radiotherapy (RT) and underwent reRT during 2006-2016. Medical records and RT details of the primary tumor treatments and rectal cancer recurrence treatments were registered, including details on reRT, chemotherapy, surgery, adverse events, and long-term outcomes. Results: Of 77 patients who received ReRT, 67 had previously received pelvic RT for rectal cancer and were administered reRT for LRRC. Re-irradiation doses were 30.0-45.0 Gy, most often given as hyperfractionated RT in 1.2-1.5 Gy fractions twice daily with concomitant capecitabine. The median time since initial RT was 29 months (range, 13-174 months). Of 36 patients considered as potentially resectable, 20 underwent surgery for LRRC within 3 months after reRT. Operated patients had better 3-year overall survival (OS) (62%) compared to those who were not operated (16%; HR 0.32, p  = .001). The median gross tumor volume (GTV) was 107 cm 3 , and 3-year OS was significantly better in patients with GTV <107 cm 3 (44%) compared to patients with GTV ≥107 cm 3 (21%; HR 0.52, p  = .03). Conclusion: Three-year survival was significantly better for patients who underwent surgery after reRT or who had small tumor volume. Prospective clinical trials are recommended for further improvements in patient selection, outcomes, and toxicity assessment.

Background and Objectives: Recent studies demonstrating decreased survival following minimally invasive surgery (MIS) for cervical cancer have generated concern regarding oncologic efficacy of MIS. Our objective was to evaluate the association between surgical approach and 5-year survival following resection of abdominopelvic malignancies., Methods: Patients with stage I or II adenocarcinoma of the prostate, colon, rectum, and stage IA2 or IB1 cervical cancer from 2010-2015 were identified from the National Cancer Data Base. The association between surgical approach and 5-year survival was assessed using propensity-score-matched cohorts. Distributions were compared using logistic regression. Hazard ratio for death was estimated using Cox proportional-hazard models., Results: The rate of deaths at 5 years was 3.4% following radical prostatectomy, 22.9% following colectomy, 18.6% following proctectomy, and 6.8% following radical hysterectomy. Open surgery was associated with worse survival following radical prostatectomy (HR, 1.18; 95% CI, 1.05-1.33; P = .005), colectomy (HR, 1.45; 95% CI, 1.39-1.51; P < .001), and proctectomy (HR, 1.28; 95% CI, 1.10-1.50; P = .002); however, open surgery was associated with improved survival following radical hysterectomy (HR, 0.61; 95% CI, 0.44-0.82; P = .003)., Conclusions: These results suggest that MIS is an acceptable approach in selected patients with prostate, colon, and rectal cancers, while concerns regarding MIS resection of cervical cancer appear warranted., (© 2020 Wiley Periodicals, Inc.)

Background: Anal squamous cell carcinoma (ASCC) is the most common histological subtype of anal cancer. Rates have been observed to increase in recent years. Combined chemoradiotherapy (CCRT) is currently the gold standard of treatment. The aim of this study is to assess ASCC prevalence, treatment trends, and overall survival (OS) in the United States., Methods: Patients diagnosed with stage I-IV ASCC were identified from the National Cancer Database from 2004 to 2015. The primary outcome was 5-year OS, which was analyzed using Kaplan-Meier survival curves, log-rank test, and Cox proportional hazards models., Results: 34,613 cases were included (stage I: 21.45%; II: 41.00%; III: 31.62%; IV: 5.94%), with an increasing trend in prevalence. CCRT was the most used treatment. Multimodal treatment, combining surgery with CCRT, offered the best OS rates for stage I, II, and IV cancers (I: 84.87%; II: 75.12%; IV: 33.08%), comparable with survival of stage III patients treated with CCRT (III: 61.14%). Radiation alone had the worse OS rates, and on adjusted analysis, radiation treatment alone had the greatest risk of mortality (I: hazard ratio, 2.01; 95% confidence interval, 1.14-3.54; P = 0.016; II: 2.05, 1.44-2.93, P < 0.001; IV: 1.99, 0.99-4.02, P = 0.054)., Conclusions: ASCC has increased in prevalence, notably in stage III and IV disease. Although CCRT is the most commonly used treatment type for all stages of ASCC, multimodal treatment offers better OS in stages I, II, and IV. Treatment with radiation alone offers the worst OS no matter the stage and should no longer be used as a solitary treatment modality., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate the effect of the interval between CRT and surgery on radiation proctitis, the pathologic response, and postoperative morbidity., Methods: This was a cohort study from a phase III, randomized controlled trial (FOWARC study, NCT01211210). Data were retrieved from the leading center of the trial. Patients were divided into the short-interval (≤7 weeks) group and the long-interval (>7 weeks) group. The rate of radiation proctitis, pathologic complete regression (pCR) and morbidities were calculated for each group. Multivariate analysis was used to verify the impact of interval on radiation proctitis., Results: Surgery was performed in 60 patients after an interval of ≤7 weeks and in 97 patients after an interval of >7 weeks. The two groups according to interval were comparable in terms of baseline demographic and clinicotherapeutic characteristics. Radiation proctitis was identified by imaging in 9 (15.0%) patients in short-interval group and in 31 (32.0%) patients in long-interval group (P = .018). Multivariate analysis confirmed the correlation between long interval and radiation proctitis (P = .018). The long interval was significantly associated with longer median operation time compared to the short interval (P = .022). The rates of pCR and postoperative complications were not different between two groups., Conclusions: A longer interval after CRT may be associated with higher rate of radiation proctitis and longer operation time. Moreover it did not increase the rate of pCR., (© 2019 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Aim: The purpose of this study was review results of pediatric patients undergoing total colectomy and restorative surgery for ulcerative colitis (UC) in a regional pediatric surgical center., Methods: A retrospective case note analysis of consecutive patients undergoing colectomy for UC between 1995 and 2014 was performed. Early complications were defined as occurring within 30 days of surgery. Data was expressed as median (range)., Results: Of 39 children who had colectomy (59% female), 21 J-pouch procedures (20 three-staged) were undertaken at our center at median age 13 years (6-17 years). Length of stay (LOS) after colectomy was 8 days (6-21) with five early and eight late complications. LOS after J-pouch ileo-anal anastomosis was 7 days (5-19 days) with two early and three late complications. After ileostomy closure LOS was 6 days (4-16 days) with three early and two late complications. The most frequent complication following each surgical stage was bowel obstruction. There was only one pouch loss, which was secondary to development of Crohn's disease (CD), and three other patients with J-pouches also subsequently developed CD 1.5 to 10 years after their original colectomy but retained their pouch. Bowel frequency at 1-2 years post J-pouch in 14 patients was a median of 4 per 24 h (2-7 per 24 h)., Conclusion: When all three postoperative stages were considered, two thirds of patients developed complications resulting in 15 additional visits to the operating theater. One in five patients subsequently developed CD after J-pouch. This should be carefully considered during pre-operative counseling., Type of Study: Retrospective Study., Level of Evidence: Level IV., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Patients undergoing radical pelvic surgery such as proctectomy or radical cystectomy are at risk of experiencing a variety of complications. Frailty renders patients vulnerable to adverse events. We hypothesize that frailty measured preoperatively using a validated scoring system correlates with increased likelihood of experiencing Clavien-Dindo grade IV complications and 30-day mortality and may be used as a predictive model for patients preoperatively. The NSQIP database was queried for patients who underwent proctectomy or radical cystectomy from 2008 to 2012. Preoperative frailty was calculated using the 11-point modified frailty index (MFI). Patients were scored based on the presence of indicators and categorized into two groups (<3 or ≥3). Major postoperative morbidities and mortality were identified and analyzed in each group. 10,048 proctectomy and cystectomy patients were identified. The MFI was found to be predictive of both 30-day mortality ( P < 0.0001) and Clavien-Dindo grade IV complications ( P < 0.0001). Receiver operating characteristic analysis demonstrated improved discriminative power of the MFI with the addition of American Society of Anesthesiologists class for both prediction of complications and 30-day mortality. An MFI score of ≥3 is predictive of postoperative morbidity and mortality. Providers should be encouraged to calculate frailty preoperatively to predict adverse outcomes.

Background: Early data suggest that transanal total mesorectal excision (TaTME) is a safe alternative to the abdominal approach for rectal cancer. This study aims to understand the approach to the management of rectal cancer in Canada and to ascertain perspectives on introducing TaTME., Methods: Surgeons were invited to complete a survey that asked about their management practices relating to rectal cancer and their opinions regarding TaTME., Results: Ninety-four surgeons completed the survey (38% response rate). The number of rectal cancer cases handled annually by surgeons varied widely (1–80 cases, median 15 cases). Twenty-seven percent of respondents performed TaTME at the time of the survey, and 43% of those who did not said they planned on learning the technique. Surgeons who performed TaTME felt that a higher annual volume of rectal cancer cases was required to maintain proficiency than did non-TaTME surgeons (median 20 cases [interquartile range (IQR) 15–25 cases] v. 15 cases [IQR 10–20 cases]). Surgeons who performed TaTME also felt that a higher annual volume of TaTME cases was required to maintain proficiency (median 12 cases [IQR 10–19 cases] v. 9 cases [IQR 5–10 cases])., Conclusion: These findings help define the current practice environment for rectal cancer surgeons in Canada and highlight the complex issues associated with learning TaTME., Competing Interests: None declared., (© 2020 Joule Inc. or its licensors)

Background: The role of robotic surgery in colorectal cancer remains contentious with most data arising from small, single-institution studies., Methods: Stage I-III colorectal cancer resections from 2008 to 2014 were identified in New York State. Propensity score-adjusted negative binomial models were used to compare cost and utilization between robotic, laparoscopic, and open resections., Results: A total of 12,218 patients were identified. For colectomy, the robotic-to-open conversion rate was 3%, and the laparoscopic-to-open conversion rate was 13%. For rectal resection, the robotic-to-open conversion rate was 7% and the laparoscopic-to-open conversion rate was 32%. In intention-to-treat analysis, there was no significant difference in cost across the surgical approaches, both in overall and stratified analyses. Both laparoscopic and robotic approaches were associated with decreased 90-d hospital utilization compared with open surgery in intention-to-treat analyses., Conclusions: Robotic and laparoscopic colorectal cancer resections were not associated with a hospital cost benefit after 90 d compared with open but were associated with decreased hospital utilization. Conversion to open resection was common, and efforts should be made to prevent them. Future research should continue to measure how robotic and laparoscopic approaches can add value to the health care system., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: Human papillomavirus (HPV)-related anal squamous cell dysplasia has been well-reported in high-risk (HR) patients [human immunodeficiency virus (HIV)-positive, men having sex with men (MSM) or immune-suppressed transplant recipients]. However, data are extremely limited for all other patients. This study reports treatment outcomes for HPV-related dysplasia in a population of non-HR patients., Method: A retrospective study was performed to review treatment efficacy in non-HR patients diagnosed with anal dysplasia or superficially invasive squamous cell carcinoma of the anus (SISCCA) with at least 12-months' follow-up; HR patients were excluded. Medical records were reviewed for demographics, pathology, cytopathology, treatment and recurrences., Results: Forty-one patients were identified (34 women). The median age at diagnosis was 58 years (range 26-85) and median follow-up was 26 months (range 12-51). At diagnosis, 36 patients had anal dysplasia and five patients had SISCCA. Treatment outcomes (resolved versus recurrent) differed between treatment modalities (P = 0.014). Topical and fulguration-only treatment modalities were superior to wide local excision (WLE) (P < 0.006 and P < 0.008, respectively). Fourteen (39%) patients had recurrent dysplasia at a median of 14 months (range 4-62); eight patients developed a second recurrence at a median of 14 months (range 11-26). No SISCCA patient had a recurrence, but two patients progressed to anal cancer after treatment., Conclusion: The behaviour of anal dysplasia reported in this under-represented, small group of non-HR patients reveals that treatment for anal dysplasia is not necessarily a single event and nonexcisional treatments may be favourable to WLE. Though the true denominator of this population is unknown, treatment may not prevent the recurrence of dysplasia or progression to cancer, warranting close follow-up., (Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.)

Background: Venous thromboembolism (VTE) is the most common preventable cause of 30-day post-operative mortality, with many events occurring after hospital discharge. High-level evidence supports post-discharge VTE chemoprophylaxis following abdominal/pelvic cancer resection; however, some studies support a more tailored approach. Our objectives were to (1) identify risk factors associated with post-discharge VTE in a large cohort of patients undergoing colorectal cancer resection and (2) develop a post-discharge VTE risk calculator., Methods: Patients who underwent colorectal cancer resection from 2012 to 2016 were identified from ACS NSQIP colectomy and proctectomy procedure-targeted modules. Multivariable logistic regression was used to identify factors associated with post-discharge VTE. Incorporating pre-operative, intra-operative, and post-operative variables, a post-discharge VTE risk calculator was constructed and validated., Results: Of 51,139 patients, 387 (0.76%) developed post-discharge VTE. Pre-operative factors associated with post-discharge VTE included BMI (e.g., morbidly obese OR 2.27, 95% CI 1.65-3.12 vs. normal BMI), and thrombocytosis (OR 1.41, 95% CI 1.03-1.92). Intra-operative factors included operative time (4-6 h OR 1.56, 95% CI 1.12-2.17; > 6 h, OR 1.85, 95% CI 1.21-2.84, vs. < 2 h), and type of operation (e.g., open partial colectomy OR 1.67, 95% CI 1.30-2.16 vs. laparoscopic partial colectomy). Post-operative factors included anastomotic leak (OR 2.05, 95% CI 1.31-3.21) and post-operative ileus (OR 1.39, 95% CI 1.07-1.79). Using the risk calculator, the predicted probability of post-discharge VTE ranged from 0.04 to 10.29%. On a 10-fold cross validation, the calculator's mean C-Statistic was 0.65., Conclusions: Patient-specific factors are associated with varying rates of post-discharge VTE. We present the first post-discharge VTE risk calculator designed for use at the time of discharge following colorectal cancer resection.

Background: Transanal total mesorectal excision (TaTME) for rectal cancer has emerged as an alternative to the traditional abdominal approach. However, concerns have been raised about local recurrence. The aim of this study was to evaluate local recurrence after TaTME. Secondary aims included postoperative mortality, anastomotic leak and stoma rates., Methods: Data on all patients who underwent TaTME were recorded and compared with those from national cohorts in the Norwegian Colorectal Cancer Registry (NCCR) and the Norwegian Registry for Gastrointestinal Surgery (NoRGast). Kaplan-Meier estimates were used to compare local recurrence., Results: In Norway, 157 patients underwent TaTME for rectal cancer between October 2014 and October 2018. Three of seven hospitals abandoned TaTME after a total of five procedures. The local recurrence rate was 12 of 157 (7·6 per cent); eight local recurrences were multifocal or extensive. The estimated local recurrence rate at 2·4 years was 11·6 (95 per cent c.i. 6·6 to 19·9) per cent after TaTME compared with 2·4 (1·4 to 4·3) per cent in the NCCR (P < 0·001). The adjusted hazard ratio was 6·71 (95 per cent c.i. 2·94 to 15·32). Anastomotic leaks resulting in reoperation occurred in 8·4 per cent of patients in the TaTME cohort compared with 4·5 per cent in NoRGast (P = 0·047). Fifty-six patients (35·7 per cent) had a stoma at latest follow-up; 39 (24·8 per cent) were permanent., Conclusion: Anastomotic leak rates after TaTME were higher than national rates; local recurrence rates and growth patterns were unfavourable., (© 2019 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Background: Controversy exists regarding the optimal surveillance strategy following local excision of T1NX rectal adenocarcinoma. This study aims to determine the cost-effectiveness of surveillance strategies for locally excised T1NX rectal adenocarcinoma based on histopathologic and local staging risk factors., Methods: A Markov model with 10-year follow-up was developed for cost-effectiveness analysis of high-, medium-, and low-intensity surveillance strategies after local excision of T1NX rectal adenocarcinoma. Literature review and expert consensus were utilized to populate state/transition probabilities and rewards. Based on this data, 87% of T1NX patients undergoing local excision were low risk. Healthcare utilization costs were based on Centers for Medicare and Medicaid Services data. The primary outcomes were costs in 2018 US dollars and effectiveness in life-years presented as net monetary benefit and incremental cost-effectiveness ratios. One-way sensitivity and probabilistic sensitivity analyses were performed., Results: Net monetary benefit for low-, medium-, and high-intensity surveillance strategies ($393,117.00, $397,978.80, and $397,290.00) shows medium-intensity surveillance to be optimal. One-way sensitivity analysis shows medium-intensity surveillance to be optimal when the cohort is 73-94% low risk. High-intensity surveillance is preferred when less than 73% of the cohort is low risk. Low-intensity surveillance is preferred when greater than 94% is low risk. Probabilistic sensitivity analysis of the base-case shows medium-intensity surveillance is the optimal strategy for 51.5% of the iterations performed., Conclusions: Medium-intensity surveillance is the most cost-effective surveillance strategy for locally excised T1NX rectal adenocarcinoma in a clinically representative population model.

Background: To understand how surgeon expectation of case difficulty relates to workload for colon and rectal procedures and to identify possible surgeon-perceived drivers contributing to case difficulty., Materials and Methods: For 3 mo, surgeons were asked to complete a modified NASA-Task Load Index (NASA-TLX) questionnaire following each surgical case. Questions included items on distractions, fatigue, procedural difficulty, and expectation plus the validated NASA-TLX items. All but expectation were rated on a 20-point scale (0 = low, 20 = high). Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less difficult than expected). Surgeons also reported perceived drivers contributing to case ease or difficulty. Patient and procedural data were analyzed for procedures with completed surveys., Results: Seven surgeons (three female) rated 122 procedures over the research period using a modified NASA-TLX survey. Mean surgeon-perceived workload was highest for effort (mean [M] = 10.83, standard deviation [SD] = 5.66) followed by mental demand (M = 10.18, SD = 5.17), and physical demand (M = 9.19, SD = 5.60). Procedural difficulty varied significantly by procedure type (P < 0.001). Thirty-five percent of cases were considered more difficult than expected. Surgeon-perceived workload and most subscales differed significantly according to expectation level. There was no significant difference in patient factors by expectation level. Surgeons most frequently reported patient anatomy, body habitus, and operative team characteristics as drivers to difficulty and ease of cases., Conclusions: Procedural difficulty significantly differed across procedure type. More than one-third of cases were more difficult than expected, during which surgeons attributed this to operative team characteristics as well as issues in patient anatomy and body habitus., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Mucinous adenocarcinoma (MA) is a distinct histotype of rectal cancer, possibly having prognostic differences with adenocarcinoma (AD). We investigated the prognostic significance of mucinous histology in patients with Stage II rectal cancer., Patients and Methods: Eligible patients were retrieved from the Surveillance, Epidemiology, and End Results database from 2004 to 2017, and the survival difference between AD and MA patients in the overall and subgroup populations (divided by age) was compared. Multivariate Cox proportional hazard regression analysis was performed to assess whether the mucinous histotype was an independent prognostic factor., Results: A total of 10, 910 patients with Stage II rectal cancer were enrolled and divided into a young group (≤55 years, n = 3248) and an old group (>55 years, n = 7662). Patients with MA exhibited a lower cancer-specific survival rate than those with common AD in the overall population and the young group, but not in the old group. The analysis revealed that the mucinous histotype was an independent prognostic factor in the young group, but not in the old group. Moreover, after excluding patients with risk factors (including poorly differentiated or undifferentiated tumor grade, T4 stage, <12 lymph nodes examined, and elevated preoperative carcinoembryonic antigen level), prognosis of the mucinous histotype was poorer in the young group than that in the old group., Conclusion: The mucinous histotype was an independent prognostic factor in young patients with Stage II rectal cancer. The presence of mucinous histology reflected poor prognosis, especially in the low-risk young population., Competing Interests: None