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The receptor tyrosine kinase EphB2 is expressed by colon progenitor cells; however, only 39% of colorectal tumors express EphB2 and expression levels decline with disease progression. Conversely, EphB4 is absent in normal colon but is expressed in all 102 colorectal cancer specimens analyzed, and its expression level correlates with higher tumor stage and grade. Both EphB4 and EphB2 are regulated by the Wnt pathway, the activation of which is critically required for the progression of colorectal cancer. Differential usage of transcriptional coactivator cyclic AMP-responsive element binding protein–binding protein (CBP) over p300 by the Wnt/β-catenin pathway is known to suppress differentiation and increase proliferation. We show that the β-catenin-CBP complex induces EphB4 and represses EphB2, in contrast to the β-catenin-p300 complex. Gain of EphB4 provides survival advantage to tumor cells and resistance to innate tumor necrosis factor-related apoptosis-inducing ligand–mediated cell death. Knockdown of EphB4 inhibits tumor growth and metastases. Our work is the first to show that EphB4 is preferentially induced in colorectal cancer, in contrast to EphB2, whereby tumor cells acquire a survival advantage. [Cancer Res 2009;69(9):3736–45]

Supplementary Methods and Figure Legends 1-11 from Preferential Induction of EphB4 over EphB2 and Its Implication in Colorectal Cancer Progression

Supplementary Figures 1-11 from Preferential Induction of EphB4 over EphB2 and Its Implication in Colorectal Cancer Progression

BACKGROUND Accurate and comprehensive surgical pathology reports are integral to the quality of cancer care. Despite guidelines from the College of American Pathologists, variations in reporting quality continue to exist. OBJECTIVE The aim of this study was to evaluate the quality of rectal cancer pathology reports and to identify areas of deficiency and potential sources of reporting variations. DESIGN This is a retrospective analysis of prospectively obtained pathology reports. SETTING This study is based at the hospitals participating in the National Surgical Adjuvant Breast and Bowel Project Protocol R-04 study. PATIENTS Patients with rectal cancer undergoing surgical resection between July 2004 and August 2010 were included. MAIN OUTCOME MEASURES The primary outcomes measured were the adherence to the College of American Pathologists guidelines and the impact of synoptic reporting, academic status, rural/urban setting, and hospital bed size on reporting quality. RESULTS We identified 1004 surgical pathology reports for rectal cancer surgery from 383 hospitals and 755 pathologists. The overall adherence rate to the College of American Pathologists guidelines was 73.3%. Notable reporting deficiencies were found in several key pathology characteristics, including tumor histologic grade (reporting rate 77.8%), radial margin (84.6%), distance from the closest margin (47.9%), treatment effect (47.1%), and lymphovascular (73.1%)/perineural invasions (35.4%). Synoptic reporting use and urban hospital settings were associated with better adherence rates, whereas academic status and hospital bed size had no impact. Reporting variations existed not only between institutions, but also within individual hospitals and pathologists. There was a trend for improved adherence over time (2005 = 65.7% vs 2010 = 82.3%, p < 0.001), which coincided with the increased adoption of synoptic reporting by pathologists (2005 vs 2010, 9.4% vs 25.3%, p < 0.001). LIMITATIONS Data were obtained from a restricted setting (ie, hospitals participating in a randomized clinical trial). CONCLUSIONS Wide variations in the quality of pathology reporting are observed for rectal cancer. The National Accreditation Program for Rectal Cancer mandates that programs meet strict quality standards for surgical pathology reporting. Further improvement is needed in this key aspect of oncology care for patients with rectal cancer. See Video Abstract at http://links.lww.com/DCR/B238.ClinicalTrials.gov registration: NCT00058 EVALUACION DE LA CALIDAD DE LOS INFORMES DE PATOLOGIA QUIRURGICA EN CASOS DE CANCER DE RECTO DEL NSABP R-04/ ONCOLOGIA DEL NRG: Un informe de patologia quirurgica preciso y completo es fundamental en la calidad de atencion de pacientes con cancer. A pesar de las normas establecidas por el Colegio Americano de Patologia, la variabilidad en la calidad de los informes es evidente.Evaluar la calidad de los informes de patologia en casos de cancer de recto para asi identificar las areas con deficiencias y las posibles fuentes variables en los mencionados informes.Analisis retrospectivo de informes de patologia quirurgica obtenidos prospectivamente.Hospitales que participan del Protocolo del Estudio Nacional R-04 como Adyuvantes Quirurgicos de Mama e Intestino.Todos aquellos pacientes con cancer de recto sometidos a reseccion quirurgica entre Julio 2004 y Agosto 2010.Cumplimiento de las normas del Colegio Americano de Patologia, del impacto de los informes sinopticos, del estado academico, del entorno rural / urbano y el numero de camas hospitalarias en en la calidad de los informes.Identificamos 1,004 informes de patologia quirurgica en casos de cirugia en cancer de recto en 383 hospitales y 755 patologos. La tasa general de adherencia a las directivas del Colegio Americano de Patologia fue del 73.3%. Se encontraron deficiencias notables en los informes en varias caracteristicas patologicas clave incluidos, el grado histologico del tumor (tasa de informe 77.8%), margenes radiales (84.6%), distancia del margen mas cercano (47.9%), efecto del tratamiento (47.1%) invasion linfovascular (73.1 %) / invasion perineural (35.4%). El uso de informes sinopticos y los entornos hospitalarios urbanos se asociaron con mejores tasas de adherencia, mientras que el estado academico y el numero de camas hospitalarias no tuvieron ningun impacto. Hubo variaciones en los informes no solo entre instituciones, sino tambien dentro de hospitales y patologos individuales. Hubo una tendencia a una mejor adherencia a lo largo del tiempo (2005 = 65.7% v 2010 = 82.3%, p < 0.001), que coincidio con la mayor adopcion de informes sinopticos por parte de los patologos (2005 v 2010, 9.4% v 25.3%, p < 0.001)Datos obtenidos de un entorno restringido (es decir, hospitales que participan en un ensayo clinico aleatorizado).Se observaron grandes variaciones en la calidad de los informes de patologia quirurgica en casos de cancer de recto. El Programa Nacional de Acreditacion para Cancer de Recto exige que los programas cumplan con estrictos estandares de calidad para los informes de patologia quirurgica. Se necesita una mejoria adicional en este aspecto clave de la atencion oncologica para pacientes con cancer de recto. Video Resumen en http://links.lww.com/DCR/B238.Registro de Clinical Trials.gov: NCT00058.

649 Background: This study sought to compare adverse events (AEs) of older and younger adults with lower gastrointestinal (GI) malignancies treated on NRG studies. Methods: Data from six NRG trials (RTOG 9811/0012/0247/0529/0822 & NSABP R-04), testing combined modality therapy (radiation and chemotherapy) in patients with anal or rectal cancer, were collected to test the hypothesis that older age was associated with increase in acute ( ≤ 90 days from treatment start) AEs. AEs were defined as GI, Genitourinary (GU), hematologic, or skin. AEs and compliance with protocol-directed therapy were compared between patients aged ≥ 70 years and < 70 years. Categorical variables were compared across age groups using the chi-square test. The association of age on AEs was evaluated using a covariate-adjusted logistic regression model, with odds ratio (OR) reported. To adjust for multiple comparisons, a p-value < 0.01 was considered statistically significant. Results: Data from 2525 patients were collected (43% female, 72% rectal cancer). There were 380 patients ≥ 70 years old (15%). Older patients were more likely to have worse baseline performance status (PS 1 or 2) (23% vs. 16%, p

Purpose The surgical workforce within the United States is moving rapidly toward increasing subspecialization. We hypothesized that over time an increasing proportion of colorectal procedures is performed by subspecialty-trained colorectal surgeons. Methods We used data from the Surveillance, Epidemiology, and End Results-Medicare program to examine the treatment of patients who underwent a colorectal surgical procedure between 1992 and 2002. We established whether the surgeon responsible for the patient's initial care was a board-certified colorectal surgeon based on a linkage with 2 overlapping data sources: 1) historical data from the American Board of Colon and Rectal Surgery and 2) the American Medical Association Physician Masterfile. Results We examined a total of 104,636 procedures; overall, 30.6% of anorectal procedures, 22.0% of proctectomies, 14.0% of ostomy-related procedures, and 11.5% of colectomies were performed by board-certified colorectal surgeons. Procedures in regions with lower population density or during urgent/emergent hospitalizations were more likely to be performed by a noncolorectal surgeon. Operations for cancer and those performed on an elective basis were more likely to be performed by a board-certified colorectal surgeon. Over time, the proportion of each of these types of cases performed by a colorectal surgeon increased. This increase was fastest for anorectal procedures. Conclusions During the 11-year period of our study, there was a significant increase in the proportion of colorectal surgical procedures performed by board-certified colorectal surgeons.

Purpose In choosing the appropriate surgical option for patients with colon cancer and Lynch syndrome, goals of treatment are to maximize life expectancy while preserving quality of life. This study constructs a decision model that encompasses these two related considerations. Methods We constructed a state-transition (Markov) model based on assumptions obtained from available data sources and published literature. Two strategies were considered for the treatment of colon cancer in a patient with Lynch syndrome: segmental colectomy (SEG) and total abdominal colectomy (TAC) with ileorectal anastomosis. Quality-adjusted life years (QALYs) were calculated based on utility states for patients based on the colectomy they received. Multiple sensitivity analyses were planned to examine the impact of each assumption on model results. Results For young (30-year-old) patients with Lynch syndrome, mean survival was slightly better with TAC than with SEG (34.8 v 35.5 years). When QALYs were considered, the two strategies were approximately equivalent, with QALYs per patient of 21.5 for SEG and 21.2 for TAC. With advancing age, SEG becomes a more favorable strategy. Results of our model were most sensitive to the utility state of TAC (relative to SEG), rates of metachronous occurrence, and stage of cancer at the time of such occurrence. Conclusion SEG and TAC are approximately equivalent strategies for patients with colon cancer and Lynch syndrome. The decision regarding which operation is preferable should be made on the basis of patient factors and preferences, with special emphasis on age and the ability of the patient to utilize intensive surveillance.

The treatment costs for patients in the United States with inflammatory bowel disease (IBD) exceed 1.7 billion dollars/year. Infliximab, an antibody to tumor necrosis factor-α, has been extensively used to treat IBD, with 390,000 IBD patients receiving the drug since its FDA approval in 1998. We sought to determine the impact of infliximab on population-based rates of hospitalizations and surgical care for patients with IBD in the United States. We used data from the Nationwide Inpatient Sample to analyze patterns of hospital-based treatment provided to patients with IBD between 1998 and 2005. Data from this analysis were combined with census data to calculate trends in population-based rates of treatment. Overall rates of hospitalization for patients with Crohn's disease and ulcerative colitis increased significantly between 1998 and 2005 (5.1%/year and 3.4%/year respectively, P < 0.001 for each). During the same time period there were no changes in the overall rates of surgical care. The expanding use of infliximab has not significantly impacted the use of surgical procedures for patients with either ulcerative colitis or Crohn's disease, and rates of nonsurgical hospitalizations have actually increased. Even in the era of infliximab, surgical care remains a mainstay in the treatment of IBD.

Restorative proctocolectomy with ileal pouch-anal anastomosis with or without mucosectomy has become the procedure of choice in patients with long-standing ulcerative colitis complicated by malignancy or medically refractory disease and for familial polyposis syndrome. Some reports have demonstrated the development of malignancy at the ileoanal anastomosis. We present a recent series of five patients who developed adenocarcinoma in the middle of their ileal pouch including the first case of pouch carcinoma in a patient who underwent pouch formation for ulcerative colitis. We discuss their presentation and management. Development of ileal pouch cancers, while rare, has been seen with increasing frequency in our practice. Patients with long-standing ileal pouches may benefit from routine surveillance of the pouch as often as every six months, which can be performed quickly and easily in the office using flexible endoscopy.

PURPOSE: The objective of this study was to evaluate our experience in the management of acquired rectourinary fistulas at our tertiary center. METHODS: Eighteen patients with fistulas treated from 1999 to 2004 were retrospectively reviewed for demographics, etiology of the fistulas, treatment, and outcome. RESULTS: The median age of the group was 69 years. Sixteen patients had fistulas that were malignant-associated. One patient died from tumor progression before any surgical therapy. The remaining 17 patients underwent surgical treatment of the fistula with a median of one procedure per patient. Eight patients had excision with permanent diversion, two had excision with repair/reconstructive procedures, and seven had repair surgical procedures. Initial surgical management was successful for 13 (76 percent) patients. Reoperation resulted in a final success rate of 100 percent. The rates of permanent fecal, urinary, and fecal plus urinary diversion in the malignant associated fistula group were 5.8, 47, and 5.8 percent, respectively. The median follow-up for all patients was 9.5 months. There were no procedure-related mortalities and five (29 percent) patients had significant surgical-related morbidity. CONCLUSIONS: Our data suggest that surgical treatment for acquired rectourinary fistulas can successfully avoid permanent fecal and/or urinary diversion in a large number of patients if locally curative cancer treatment can be achieved.

Postoperative ileus (POI) remains an inevitable consequence of abdominal surgery. Although the pathogenesis of delayed gastrointestinal transit in the postoperative period has been the subject of considerable study, a clinically useful definition of what constitutes a pathologically prolonged ileus has yet to be established. The objectives of this study were to describe a definition for an abnormally prolonged ileus and to identify risk factors and predictors of prolonged ileus in patients undergoing abdominal surgery.Over a 12-month period 88 patients who had abdominal surgery were retrospectively reviewed. The association of clinical factors with the duration of POI was examined with statistical tests.The mean time to commencing the consumption of unrestricted clear fluids after surgery was 2.3 +/- SD 1.6 days. The median duration of POI was 5 days (median 6 days), with an interquartile range of 3-6 days. Univariate regression analysis demonstrated significant correlations between duration of POI and estimated blood loss (EBL), total surgical time, and total opiate dose (TOD) (p = 0.009, p = 0.045, and p = 0.041, respectively). Multiple regression analysis identified EBL and TOD as independent predictors of duration of POI.We have identified two risk factors (EBL and TOD) that are independently associated with duration of POI. Our data suggest that with the definition of abnormal prolonged postoperative ileus as the number of days above the 3rd quartile, an ileus greater than 6 days serves as a better clinical definition of prolonged POI than 3 days, the measure that has previously been suggested.

Creation of a temporary ostomy is a surgical tool to divert stool from a more distal area of concern (anastomosis, inflammation, etc). To provide a true benefit, the morbidity/mortality from the ostomy takedown itself should be minimal. The aim of our study was therefore to evaluate our own experience and determine the complications and mortality of stoma closure in relation to the type and location of the respective ostomy. Patients undergoing an elective takedown of a temporary ostomy at our teaching institution between January 1999 and July 2005 were included in our analysis, and the medical records were retrospectively reviewed. Excluded were only patients with relevant chart deficiencies and nonelective stoma revisions/takedowns. Data collected included general demographics; the type and location of the stoma; the operative technique; and the type, timing, and impact of complications. Perioperative morbidity was defined as complications occurring within 30 days from the operation. 156 patients (median age 45 years, range 18–85) were included in the analysis: 31 loop and 59 end colostomy reversals and 56 loop and 10 end ileostomy takedowns. Mean follow-up was 6 months. The overall mortality rate was low (0.65%, 1/156 patients). However, the morbidity rate was 36.5% (57 patients), with 6 (3.8%) systemic complications and 51 (32.7%) local complications. Minor would infection (34 patients, 21.8%) and postoperative ileus (9 patients, 5.7%) were the most common surgery-related complications, but they generally resolved with conservative management. Anastomotic leak and formation/persistence of an enterocutaneous fistula (6 patients, 3.8%) were the most serious local complications and required reintervention in all of the patients. Closure of a loop colostomy accounted for half and Hartmann reversals for one third of these complications, as opposed to ileostomy takedowns, which accounted for only one sixth (1.8% absolute risk). Takedown of a temporary ostomy has a low mortality but a nonnegligible morbidity. The stoma location (large vs. small bowel) has a higher impact than the type of stoma construction (end vs. loop) on the incidence and severity of complications.

Purpose: Oncologic concerns from high wound recurrence rates prompted a multi-institutional randomized trial to test the hypothesis that disease-free and overall survival are equivalent, regardless of whether patients receive laparoscopic-assisted or open colectomy. Methods: Eight hundred seventy-two patients with curable colon cancer were randomly assigned to undergo laparoscopic-assisted or open colectomy at 1 of 48 institutions by 1 of 66 credentialed surgeons. Patients were followed for 8 years, with 5-year data on 90% of patients. The primary end point was time to recurrence, tested using a noninferiority trial design. Secondary endpoints included overall survival and disease-free survival. (Kaplan-Meier) Results: As of March 1, 2007, 170 patients have recurred and 252 have died. Patients have been followed a median of 7 years (range 5-10 years). Disease-free 5-year survival (Open 68.4%, Laparoscopic 69.2%, P = 0.94) and overall 5-year survival (Open 74.6%, Laparoscopic 76.4%, P = 0.93) are similar for the 2 groups. Overall recurrence rates were similar for the 2 groups (Open 21.8%, Laparoscopic 19.4%, P = 0.25). These recurrences were distributed similarly between the 2 treatment groups. Sites of first recurrence were distributed similarly between the treatment arms (Open: wound 0.5%, liver 5.8%, lung 4.6%, other 8.4%; Laparoscopic: wound 0.9%, liver 5.5%, lung 4.6%, other 6.1%). Conclusion: Laparoscopic colectomy for curable colon cancer is not inferior to open surgery based on long-term oncologic endpoints from a prospective randomized trial.

Data on colorectal cancer (CRC) in HIV-positive patients are limited. The objective of this study was to investigate the incidence, presentation, and outcome of CRC in HIV patients. Clinical data on patients diagnosed with CRC and concurrent HIV/AIDS infection between 1994 and 2003 were retrieved from the institutional records. Each identified patient was randomly matched with two HIV-negative CRC patients based on age, sex, race, and TNM stage at cancer diagnosis. Presentation, treatment toxicities, recurrence, and overall survival rates were assessed. Data were further compared with those of the published international Surveillance Epidemiology and End Results (SEER) data. Out of 3,951 CRC patients, 12 HIV CRC patients (0.3%) were identified. Median age at cancer diagnosis was 41 years (29–52), revealing a 3:1 ratio between patients younger and older then 50 years, compared to a 1:33 ratio in the general population. Compared to 57% in the general population, 90% of the patients had advanced stages (III–IV) at diagnosis. The median follow-up time for both cases and controls was 30 months (6–65). HIV-positive patients had a shorter disease-free survival than the controls. No difference in overall survival was demonstrated, however survival was significantly reduced in the HIV-positive patients when only patients who were initially disease-free were compared. Adjuvant therapy was well-tolerated in all patients without chemotherapy-related deaths. HIV-positive CRC patients tend to have an early and more aggressive presentation with less favorable outcome. Further epidemiology studies to refute or accept our observations may suggest a reduced threshold for screening for CRC in HIV-positive patients.

ObjectiveNational Surgical Adjuvant Breast and Bowel Project (NSABP) R-04 was a randomized controlled trial of neoadjuvant chemoradiotherapy in patients with resectable stage II-III rectal cancer. We hypothesized that patients who underwent abdominoperineal resection (APR) would have a poorer quality of life than those who underwent sphincter-sparing surgery (SSS).MethodsTo obtain patient-reported outcomes (PROs) we administered two symptom scales at baseline and 1 year postoperatively: the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) and the European Organization for the Research and Treatment of Cancer module for patients with Colorectal Cancer Quality of Life Questionnaire (EORTC QLQ-CR38). Scoring was stratified by nonrandomly assigned definitive surgery (APR vs SSS). Analyses controlled for baseline scores and stratification factors: age, sex, stage, intended surgery, and randomly assigned chemoradiotherapy.ResultsOf 1,608 randomly assigned patients, 987 had data for planned analyses; 62% underwent SSS; 38% underwent APR. FACT-C total and subscale scores were not statistically different by surgery at 1 year. For the EORTC QLQ-CR38 functional scales, APR patients reported worse body image (70.3 vs 77.0, P = 0.0005) at 1 year than did SSS patients. Males undergoing APR reported worse sexual enjoyment (43.7 vs 54.7, P = 0.02) at 1 year than did those undergoing SSS. For the EORTC QLQ-CR38 symptom scale scores, APR patients reported worse micturition symptoms than the SSS group at 1 year (26.9 vs 21.5, P = 0.03). SSS patients reported worse gastrointestinal tract symptoms than did the APR patients (18.9 vs 15.2, P < 0.0001), as well as weight loss (10.1 vs 6.0, P = 0.002).ConclusionsSymptoms and functional problems were detected at 1 year by EORTC QLQ-CR38, reflecting different symptom profiles in patients who underwent APR than those who underwent SSS. Information from these PROs may be useful in counseling patients anticipating surgery for rectal cancer.

This report reviews a prospective database applying a systematic fistulomy technique in 101 patients requiring surgery for fistula in ano at LAC+USC Medical Center during a 15-month period. Data were collected for the reliability of primary crypt palpation, success of tract injection with peroxide/methylene blue, and the accuracy of Goodsall's rule. Time to healing, recurrence, and incontinence according to type of procedure were also recorded. Palpation of the primary crypt was possible in 93 per cent. Hydrogen peroxide/methylene blue injection successfully delineated the tract in 83 per cent. Goodsall's rule was correct in 81 per cent. Each fistula was categorized as intersphincteric (n = 72), transphincteric (n = 33), extrasphincteric (n = 1), or sub-mucosal (n = 6). At a mean follow-up period of 44 weeks, 89.2 per cent of patients were cured. Reasons for recurrence included wound bridging (n = 6), misdiagnosis of the tract (n = 3), and two blind-ended fistulae (n = 2). Time to healing in weeks was (mean, range): simple fistulotomy (12, 3–21), seton (16, 4–28), Hanley procedure (28, 8–48). Patients with a marsupialized tract healed at an average of 6 weeks (range 4–8). Four (3.9%) patients reported postoperative incontinence (1 gas, 3 liquid, 0 solids).

TNM staging in colon cancer has several limitations. Prognostic molecular markers are now being developed to address these limitations. The aim of this study was to identify a combination of genes and markers whose expression is predictive of nodal status and outcome in colon cancer. The expression of 12 genetic markers were examined in 66 node-positive and 65 node-negative T3 colon cancers. Gene expression was quantified using real-time polymerase chain reaction. Microsatellite instability status was available through the registry. Association with lymph node status was examined using univariate and multivariate logistic regression. Thymidylate synthase expression was statistically significantly associated with lymph node status (odds ratio 0.36; 95% confidence interval: 0.16-0.81). Microsatellite instability and the other genes were not associated with nodal status. Multiple logistic regression did not identify a significant multivariate predictive model. Decreased expression of thymidylate synthase is associated with a higher risk of lymph node metastasis in patients with T3 colon cancers. Microsatellite instability and the expression of other genes are not predictive of nodal status in this population. Thymidylate synthase gene expression may help identify patients at greater risk for progression of disease.

Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis.We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, "diverticulitis" mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (40 yr,40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis.In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%.CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patient's age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.

This study was designed to review experience at our hospital with retained colorectal foreign bodies. We reviewed the consultation records at Los Angeles County + University of Southern California General Hospital from October 1993 through October 2002. Ninety-three cases of transanally introduced, retained foreign bodies were identified in 87 patients. Data collected included patient demographics, extraction method, location, size and type of foreign body, and postextraction course. Of 93 cases reviewed, there were 87 individuals who presented with first-time episodes of having a retained colorectal foreign body. For these patients, bedside extraction was successful in 74 percent. Ultimately, 23 patients were taken to the operating room for removal of their foreign body. In total, 17 examinations under anesthesia and 8 laparotomies were performed (2 patients initially underwent an anesthetized examination before laparotomy). In the eight patients who underwent exploratory laparotomy, only one had successful delivery of the foreign object into the rectum for transanal extraction. The remainder required repair of perforated bowel or retrieval of the foreign body via a colotomy. In our review, a majority of cases had objects retained within the rectum; the rest were located in the sigmoid colon. Fifty-five percent of patients (6/11) presenting with a foreign body in the sigmoid colon required operative intervention vs. 24 percent of patients (17/70) with objects in their rectum (P = 0.04). This is the largest single institution series of retained colorectal foreign bodies. Although foreign objects located in the sigmoid colon can be retrieved at the bedside, these cases are more likely to require operative intervention.

The aim of this study was to determine if the prevalence and distribution of anorectal pathology in HIV-infected patients treated by colorectal surgeons have changed after the introduction of highly active antiretroviral therapy. The Los Angeles County–University of Southern California HIV Clinic is solely dedicated to the care of HIV patients. A colorectal clinic was established within this environment in 1991 and has served as the exclusive provider for the care of anorectal pathology in these patients. A prospective database of patients treated at this clinic was reviewed for two 18-month periods. The first group (early period) was composed of patients treated between January 1994 through June 1995, before the institution of more effective antiretroviral therapy. The second group (later period) consisted of patients treated between January 2001 through June 2002, after the introduction of highly active antiretroviral therapy. Data were tabulated for HIV-related anorectal pathologies, such as anal ulcer and anogenital condyloma, and non-HIV-related pathologies, including fissure, fistula in ano, hemorrhoids, perianal abscess, and other pathologies, for each of the two time periods A total of 117 individual patients with anorectal pathology were treated in the early period and 109 received care in the later period, of which 107 were able to be evaluated. The pathology was distributed as follows for the early vs. late periods: 33 vs. 33 percent for ulcer, 30 vs. 34 percent for condyloma, 9 vs. 4 percent for fissure, 6 vs. 6 percent for fistula, 4 vs. 5 percent for hemorrhoids, 3 vs. 3 percent for abscess, and 15 vs. 16 percent for all other anorectal pathology. There was no statistically significant difference in any of these groups. The prevalence and distribution of both HIV-related and non-HIV-related anorectal pathology seen in our HIV patients have not been altered by the introduction of highly active antiretroviral therapy.

Background The frequency of Internet use for self-directed medical care in different patient populations is increasing. We evaluated Internet use by patients presenting for bariatric surgery. Study design Surveys were completed by 136 patients (109 women, 22 men) presenting to a private academic clinic for bariatric surgery. Data collected included age, gender, education level, household income, and pattern of Internet use. Comparisons were made with a group of 135 patients who visited a colorectal surgery clinic in the same institution. Results Bariatric patients who used the Internet were more likely than colorectal patients to inform themselves about their medical problem (76% versus 49%, p Conclusions Bariatric patients are especially likely to use the Internet to gain information about their medical condition, possibly reflecting their limited mobility. This represents an educational opportunity for the surgical community.

The goal of this study is to understand the role of the Internet in the education and recruitment of patients within colorectal surgery practices. Surveys of Internet use were completed by 298 patients visiting five outpatient colorectal surgery clinics affiliated with the University of Southern California. Data collected included the patient's age, gender, level of education, zip code at home, type of clinic visited, and information on the respondent's Internet use. Overall, 20 per cent of the respondent patients visiting our clinics had used the Internet to research the medical condition that prompted their visit. Highest grade level completed ( P < 0.001), age ( P < 0.01), type of clinic ( P < 0.001), and household income ( P < 0.001) were all found to be associated with any prior use of the Internet whereas gender was not ( P = 0.58). Among Internet users, only household income and frequent use of the Internet were associated with searching the Internet for medical information ( P < 0.001). Ultimately, all of the Internet-using patients surveyed felt the medical information they found was “somewhat” or “very helpful.” Understanding which patients “go online” to search for medical information is essential for surgeons who wish to use the Internet for marketing their practices and educating their patients.

background Minimally invasive, laparoscopically assisted surgery was first considered in 1990 for patients undergoing colectomy for cancer. Concern that this approach would compromise survival by failing to achieve a proper oncologic resection or adequate staging or by altering patterns of recurrence (based on frequent reports of tumor recurrences within surgical wounds) prompted a controlled trial evaluation. methods We conducted a noninferiority trial at 48 institutions and randomly assigned 872 patients with adenocarcinoma of the colon to undergo open or laparoscopically assisted colectomy performed by credentialed surgeons. The median follow-up was 4.4 years. The primary end point was the time to tumor recurrence. results At three years, the rates of recurrence were similar in the two groups — 16 percent among patients in the group that underwent laparoscopically assisted surgery and 18 percent among patients in the open-colectomy group (two-sided P=0.32; hazard ratio for recurrence, 0.86; 95 percent confidence interval, 0.63 to 1.17). Recurrence rates in surgical wounds were less than 1 percent in both groups (P=0.50). The overall survival rate at three years was also very similar in the two groups (86 percent in the laparoscopicsurgery group and 85 percent in the open-colectomy group; P=0.51; hazard ratio for death in the laparoscopic-surgery group, 0.91; 95 percent confidence interval, 0.68 to 1.21), with no significant difference between groups in the time to recurrence or overall survival for patients with any stage of cancer. Perioperative recovery was faster in the laparoscopic-surgery group than in the open-colectomy group, as reflected by a shorter median hospital stay (five days vs. six days, P

The American Society of Colorectal Surgeons (ASCRS) recently endorsed low-molecular-weight heparin and low-dose heparin as primary prophylaxis for venous thromboembolism (VTE) in highest-risk patients. Our study evaluates the feasibility of sequential compression device (SCD) use for VTE prophylaxis in these patients. Computerized databases of discharge diagnoses from three hospitals were reviewed. All patients with colorectal cancer or inflammatory bowel disease during a 7-year period were identified. Those who underwent major abdominal surgery and received VTE prophylaxis exclusively with SCDs were selected for the study. Patients diagnosed with postoperative VTE were identified through review of the three databases and of patient records for 90 days after surgery. One thousand two hundred eighty-one patients classified as highest-risk under the published ASCRS parameters underwent major abdominal surgery and received SCDs perioperatively. The incidence of clinically detectable postoperative VTE was 0.78 per cent. There were trends toward lower incidence among patients with malignancy (0.53%) compared with inflammatory bowel disease (1.48%, P = 0.09), and those with abdominal compared to pelvic procedures (0.62% vs. 1.04%, P = 0.41). Prophylaxis for perioperative VTE solely with SCD is a viable option for patients classified as highest-risk under ASCRS parameters.

INTRODUCTION: Locally recurrent rectal cancer is associated with poor quality of life and has justified aggressive surgical and adjuvant approaches to control the disease. This study was designed to evaluate the use of fractionated perioperative high-dose-rate brachytherapy in association with wide surgical excision (debulking). Our hypothesis is that this combined therapy can help control locally recurrent rectal cancer. METHODS: Patients with biopsy-proven locally recurrent rectal cancer that could not be completely removed surgically were considered candidates for this procedure. All patients had abdominal exploration, aggressive tumor debulking, and placement of afterloading brachytherapy catheters. Patients underwent simulation on postoperative Day 3 and received 1,200 to 2,500 (mean, 1,888) cGy of fractionated high-dose-rate brachytherapy between postoperative Days 3 and 5. All patients had involvement of the lateral pelvic sidewall and/or the sacrum. RESULTS: Twenty-seven patients (18 males) aged 32 to 79 years underwent therapy. Follow-up ranged from 18 to 93 (mean, 50) months and was available in 27 patients. Ten patients (37 percent) were alive at the time of this report. Nine patients are without evidence of disease. Five patients (18 percent) died of non–cancer-related causes without evidence of recurrent disease. Five complications potentially related to treatment (3 abscesses, 2 fistulas) occurred in five patients. CONCLUSION: High-dose radiation brachytherapy delivers high-dose, highly controlled, focused radiation to specific sites of disease, thereby minimizing injury to normal tissues. The results in this series suggest increased local control, better palliation, and increased salvage of patients.

The purpose of this study was to review our experience with self-expanding metal stents as the initial interventional approach in the management of acute malignant large-bowel obstruction.Twenty-six patients who underwent placement of colonic stents at our institution between June 1994 and June 2000 were identified and reviewed.In 14 patients, the stents were placed for palliation, whereas in 12, they were placed as a bridge to surgery. In 22 patients (85%), stent placement was successful on the first occasion. In the remaining four individuals, one was successfully stented at the second occasion, and three required emergency surgery. Nine of the 12 patients (75%) in the bridge-to-surgery group underwent elective colon resection. In the palliative group, four patients (29%) had reobstruction of the stents, and in one (9%), the stent migrated. In the remaining nine patients (64%), the stent was patent until the patient died or until the time of last follow-up (median, 156 days).In our experience with 26 patients who developed a complete bowel obstruction as a consequence of a malignant tumor, placement of colonic stents to achieve immediate nonoperative decompression proved to be both safe and effective. Subsequent elective resection was accomplished in the majority of resectable cases.

PURPOSE: After proctocolectomy for ulcerative colitis or familial adenomatous polyposis, creation of a continent ileostomy is one of the surgical options. Although most patients will be offered a pull-through procedure, the continent ileostomy is a valuable alternative in patients who are either not candidates for or have failed an ileal pouch-anal anastomosis or who—for other reasons—prefer a permanent ileostomy. The traditional continent reservoirs (Kock or Barnett pouch) with an intussuscepted bowel segment as valve mechanism have an unsatisfactorily high incidence of dysfunction and frequent reoperations. The objective of this study was to adapt the T-pouch valve concept, previously used for urinary reservoirs, for a continent stool reservoir and to construct a valve mechanism that omits intussusception of the bowel and maintains the blood supply to the valve segment. METHODS: The technique for the critical valve construction is described in detail. It consists of isolating the terminal segment of the small bowel with its blood supply. The valve mechanism is created by embedding this segment in a serosa-lined tunnel of two apposed limbs of bowel that will form the pouch reservoir. RESULTS: Preliminary results in six patients indicate complete continence of the pouch. CONCLUSION: Although long-term results are not yet available, the new T-pouch concept is suitable as a continent stool reservoir and promises a significant improvement as compared with the traditional Kock pouch.

Purpose The optimal chemotherapy regimen administered concurrently with preoperative radiation therapy (RT) for patients with rectal cancer is unknown. National Surgical Adjuvant Breast and Bowel Project trial R-04 compared four chemotherapy regimens administered concomitantly with RT. Patients and Methods Patients with clinical stage II or III rectal cancer who were undergoing preoperative RT (45 Gy in 25 fractions over 5 weeks plus a boost of 5.4 Gy to 10.8 Gy in three to six daily fractions) were randomly assigned to one of the following chemotherapy regimens: continuous intravenous infusional fluorouracil (CVI FU; 225 mg/m2, 5 days per week), with or without intravenous oxaliplatin (50 mg/m2 once per week for 5 weeks) or oral capecitabine (825 mg/m2 twice per day, 5 days per week), with or without oxaliplatin (50 mg/m2 once per week for 5 weeks). Before random assignment, the surgeon indicated whether the patient was eligible for sphincter-sparing surgery based on clinical staging. The surgical end points were complete pathologic response (pCR), sphincter-sparing surgery, and surgical downstaging (conversion to sphincter-sparing surgery). Results From September 2004 to August 2010, 1,608 patients were randomly assigned. No significant differences in the rates of pCR, sphincter-sparing surgery, or surgical downstaging were identified between the CVI FU and capecitabine regimens or between the two regimens with or without oxaliplatin. Patients treated with oxaliplatin experienced significantly more grade 3 or 4 diarrhea (P < .001). Conclusion Administering capecitabine with preoperative RT achieved similar rates of pCR, sphincter-sparing surgery, and surgical downstaging compared with CVI FU. Adding oxaliplatin did not improve surgical outcomes but added significant toxicity. The definitive analysis of local tumor control, disease-free survival, and overall survival will be performed when the protocol-specified number of events has occurred.

Follow-up of patients with colorectal cancer has been controversial. This is largely because studies have been small and inadequate to assess results. A recently performed meta-analysis confirms a very significant benefit to the follow-up of patients following curative resection of colorectal cancer. This article outlines the rationale and cost-effectiveness of a follow-up policy.

A major obstacle that limits the potential of human gene therapy is the inefficiency of gene delivery to appropriate sites in vivo. Previous studies demonstrated that the physiological surveillance function performed by von Willebrand factor (vWF) could be incorporated into retroviral vectors by molecular engineering of the MuLV ecotropic envelope (Env) protein. To advance the application of vWF targeting technology beyond laboratory animals, we prepared an extensive series of Env proteins bearing modified vWF-derived matrix-binding sequences and assembled these chimeric proteins into targeted vectors that are capable of transducing human cells. Initially, a dual envelope configuration was utilized, which required coexpression of a wild-type amphotropic Env. Subsequently, streamlined "escort" Env proteins were constructed wherein the inoperative receptor-binding domain of the targeting partner was replaced by the vWF-derived collagen-binding motif. Ultimately, an optimal construct was developed that exhibited properties of both extracellular matrix (ECM)-targeting and near wild-type amphotropic infectivity, and could be arrayed as a single envelope on a retroviral particle. On intraarterial instillation, enhanced focal transduction of neointimal cells (approximately 20%) was demonstrated in a rat model of balloon angioplasty. Moreover, transduction of tumor foci (approximately 1-3%) was detected after portal vein infusion of a matrix-targeted vector in a nude mouse model of liver metastasis. We conclude that the unique properties of these targeted injectable retroviral vectors would be suitable for improving therapeutic gene delivery in numerous clinical applications, including vascular restenosis, laser and other surgical procedures, orthopedic injuries, wound healing, ischemia, arthritis, inflammatory disease, and metastatic cancer.

Previous investigators have suggested that port-site recurrences are possibly a result of abdominal insufflation, forcing viable cancer cells into the circulation to metastasize and thrive in areas of trauma. Using a syngeneic animal cancer model, we tested the hypothesis that pneumoperitoneum increases the incidence of wound metastasis by a blood-borne mechanism.Male BD IX rats (N = 150) were injected intraperitoneally with 2 x 10(5) viable syngeneic 1,2-dimethylhydralazine-induced colon cancer cells (DHD-K12). Animals were divided into three groups: A (abdominal insufflation with 3-cm incision on the back into muscle remote from the peritoneum); B (3-cm back incision alone); and C (control group with 3-cm midline abdominal incision). Three weeks after surgery, the animals were euthanized and autopsied.In the two groups with back wounds, the incidence of cancer growth at the incision was zero, as demonstrated grossly and by histologic sample (A: 0/47, B: 0/43). In contrast, the autopsied control group had a 42% incidence of metastasis to the wound (25/59). There seemed to be no difference in the distribution of intra-abdominal disease between those rats that underwent insufflation and those that did not.It is unlikely that pneumoperitoneum promotes hematogenous wound implantation of free intraperitoneal cancer cells.

Recent findings in a small number of studies have suggested a trend toward increased infectious complications following laparoscopic appendectomy. The purpose of the present review was to evaluate the incidence of postappendectomy intra-abdominal abscess formation following laparoscopic and open appendectomies. Using the surgical database of the Los Angeles County-University of Southern California Medical Center, we reviewed the records of all appendectomies performed at the center between March 1993 and September 1995. Incidental appendectomies as well as appendectomies in pediatric patients under the age of 18 years were excluded. A total of 2497 appendectomies were identified; indications for these procedures included acute appendicitis in 1422 cases (57%), gangrenous appendicitis in 289 (12%), and perforated appendicitis in 786 (31%). The intraoperative diagnosis made by the surgeon was used for classification. A two-tailed P value of

PURPOSE : Few quantitative experiments evaluating colonic absorption of water and electrolytes have been performed using an awake, conscious animal model. The purpose of these experiments was to develop this type of model and evaluate both basal and meal-stimulated colonic absorption of water and electrolytes. METHODS : Canine Thiry-Vella fistulas were created using a 20 cm segment of distal colon under general anesthesia. Colonic absorption studies were performed using infusion of the Thiry-Vella fistulas with a buffer solution containing [ 14 C]polyethylene glycol. Electrolyte analysis and concentration of radioactivity in the effluent were obtained and used to calculate the net flux of water, sodium, and chloride. Each study consisted of an one-hour basal period and a three-hour experimental period divided into two groups. Group 1 received no meal. Group 2 orally ingested a mixed meal at the completion of the basal hour. RESULTS : In the basal state, water and electrolytes are absorbed from the distal colon at a steady and constant rate. An orally ingested meal produces a statistically significant increase in the rate of absorption, independent of direct colonic luminal contact with the nutrients of the meal given. CONCLUSIONS : These studies demonstrate an in vivo quantitative and qualitative measure of mammalian colonic water and electrolyte absorption. An increase in absorption rate occurs in response to a meal that is probably the result of an unidentified neural or humoral signal.

PURPOSE: Technetium-99m-labeled red blood cell scans (Tc99m RBC scan) are recommended to confirm gastrointestinal (GI) bleeding. It is controversial whether these scans are sufficient to localize the site of bleeding. This study evaluated the efficacy of RBC scans in confirming and localizing GI bleeding. Our hypothesis was that these scans were effective in localizing GI bleeding if positive within the continuous phase of imaging. METHOD: Tc99m RBC scans were performed on a total of 80 patients over a four-year period to localize GI bleeding (59 male, 21 female; age range 6–88 (mean, 48) years). Films of 75 of the 80 patients were reread by a nuclear medicine physician who was blinded to the original reading and identity and history of the patient. Results of scans were compared with confirmatory studies. RESULTS: A total of 21 patients had positive scans (28 percent). Of these, the site of bleeding in 16 of 21 patients (76 percent) was confirmed by angiography (4/16), endoscopy (10/16), surgery (10/16), or a combination of these. In 14 of the 16 confirmed studies (88 percent), RBC scan correctly localized site of bleeding by our rigid definition. In six patients (4 not confirmed, 2 erroneously localized), scans were positive only at greater than 15 hours. Ten of the 14 correctly localized studies and none of the incorrectly localized studies were positive in the continuous phase of imaging. CONCLUSION: Tc99m RBC scan is effective in localizing GI bleeding when positive within the continuous phase of imaging. In this population supplemental angiography or endoscopy for the purpose of localization would seem unnecessary.

Laparoscopic surgery has evolved rapidly since 1989. The American Society of Colon and Rectal Surgeons, the Society of American Gastrointestinal Endoscopic Surgeons, and the American College of Surgeons Commission on Cancer jointly sponsored a registry to identify as early as possible the patterns of practice and acute complications of laparoscopic colectomy. METHODS: Cases were voluntarily registered by community and academic surgeons. Information was entered in the EPI-5 database. RESULTS: One thousand fifty-six cases were contributed by 118 surgeons; 763 patients were completed laparoscopically. The most common indication for surgery was cancer in 453 patients. The right colon (n=364) and sigmoid (n=294) were most frequently resected. Respondents felt adequate cancer resections were performed. Although several unique complications were noted, intraoperative complications were similar in type and frequency to open cases. CONCLUSION: Laparoscopic colorectal surgery can be performed with acceptable complications. It remains unclear if this approach is adequate for long-term management of colon and rectal cancer.

PURPOSE: The purpose of this paper is to establish the number of cases necessary to master laparoscopic removal of the left or right colon. METHODS: Data were obtained by chart review and by individually completed questionnaires. RESULTS: A total of 144 laparoscopic-assisted or intracorporeal right or left hemicolectomies were completed by four surgeons at separate institutions. Questionnaires were completed by each surgeon for each sequential hemicolectomy, and data concerning the type of surgery and total operating time were recorded. Times were plotted to diagram individual learning curves for each surgeon, and data grouping methods were used to determine the curve for each surgeon as well as for the combined data base. Learning was said to have been completed when the surgeon's operative time reached a low point and subsequently did not vary by more than 30 minutes. A total of 78 right colectomies and 66 left colectomies were completed by the group. Respectively, each surgeon appeared to learn the procedure after 16, 21, 11, and 6 cases. When the entire database was analyzed as a whole, it was shown that between 11 and 15 completed colectomies were needed for learning, after which operative times remained relatively stable. CONCLUSIONS: This analysis, using total operative time as an indication of learning, shows that approximately 11 to 15 completed laparoscopic colectomies are needed to comfortably learn this procedure.

PURPOSE: An analysis of the existing literature on primary repair of colon injuries was undertaken to determine if there is sufficient evidence that this approach is superior to fecal diversion. METHODS: After a thorough literature search, three prospectively randomized studies comparing primary repair with fecal diversion in the management of colon injuries were identified. A variety of factors were examined, including the number of patients in each study arm, morbidity rates, as well as exclusion criteria. An analysis was performed to determine the number of patients required to establish statistical superiority of one procedure over the other. RESULTS: Pooling of the data contained in the aforementioned reports does not provide sufficient statistical power to support the superiority of primary repair of colon injuries. To demonstrate a 5 percent difference between the two approaches, a prospective, randomized study consisting of 200 patients in each arm is necessary. CONCLUSION: The present literature does not support a statistically valid advantage of primary repair over fecal diversion in the management of traumatic colon injuries.

UNLABELLED Uncertainty persists concerning the long-term results of ileal pouch-anal anastomosis performed for indeterminate colitis. PURPOSE This study was designed to compare functional outcomes of ileal pouch-anal anastomosis in patients with typical chronic ulcerative colitis and indeterminate colitis. METHOD Seventy-one ileoanal pouch patients were identified with a diagnosis of indeterminate colitis. Mean follow-up was 56 months. Outcomes were compared with 1,232 chronic ulcerative colitis patients after ileal pouch-anal anastomosis. Mean follow-up was 60 months. RESULTS (mean +/- SD) There was no difference in the frequency of daily bowel movements (indeterminate colitis, 7 +/- 3, vs. chronic ulcerative colitis, 7 +/- 2). Daytime and nighttime incontinence rates were likewise similar. Prevalence of pouchitis was identical (33 percent). However, failure rate was higher in the indeterminate colitis group (indeterminate colitis, 19 percent, vs. chronic ulcerative colitis, 8 percent; (P = 0.03)). CONCLUSIONS At a mean of nearly five years after surgery, failure appears to occur more frequently in patients with indeterminate colitis than in patients with chronic ulcerative colitis. However, the great majority of indeterminate colitis patients (> 80 percent) have long-term functional results identical to those of patients with chronic ulcerative colitis.

Background Surveillance programs are widely accepted as an integral part of the treatment plan provided to patients after surgical treatment of colorectal cancer. Despite an enormous amount of research performed regarding these programs, there is still uncertainty regarding what is appropriate surveillance. Objective We sought to systematically review recent literature regarding outcomes achieved with different types of surveillance programs for patients with surgically treated colorectal cancer. Data sources A search of the PubMed database was performed to identify studies published in the English language between January 2000 and January 2010. Study selection We included 2 types of studies in our systematic review: first, comparative studies where 2 or more surveillance strategies were applied and outcomes compared; second, single-cohort studies where the outcomes of a single surveillance strategy were reported. Main outcome measures Cancer-related outcomes included survival, recurrence detection rate, and the ability of a recurrence to be resected with curative intent. Results Our review found 15 studies meeting our inclusion criteria. Of these, 9 were comparative (4 randomized trials) and 6 were single-cohort studies. One study reported a better survival rate among patients who received more intensive follow-up. The vast majority of recurrences occurred within 3 years. Limitations Our review found that the recent literature regarding the efficacy of surveillance is inconclusive, largely because of the small sample sizes and the heterogeneity in the surveillance programs and outcomes reported. Conclusions Future randomized trials need to focus on larger sample sizes, and experimental designs should isolate specific elements of surveillance to better understand how each element contributes to improvements in patient outcomes. Risk stratification and duration of surveillance are key elements of surveillance strategies that also deserve focused investigation.

A multicenter retrospective study was undertaken to assess the efficacy and safety of laparoscopy in colon and rectal surgery. To minimize potential bias in interpretation of the results, all data were registered with an independent observer, who did not participate in any of the surgical procedures. Sixty-six patients underwent a laparoscopic procedure. Operations performed included sigmoid colectomy (19), right hemicolectomy (15), low anterior resection (6), colectomy with ileal pouch-anal anastomosis (IPAA) (5), and abdominoperineal resection (APR) (3). The conversion rate from laparoscopic colectomy to celiotomy was 41 percent. Major morbidity and mortality were 24 percent and 0 percent, respectively. Length of stay, hospital costs, and lymph node harvest were compared between the sigmoid resection and right hemicolectomy subgroups. Data from traditional sigmoid colectomies and right hemicolectomies were obtained from the same institutions for comparison. Mean postoperative stay for laparoscopically completed sigmoid and right colectomies was significantly less than that for either the converted or the traditional groups (P

Reduction of local recurrences has been achieved by radiotherapy, but also by improved surgical technique (total mesorectal excision). Radiotherapy has adverse effects and cannot exceed local dose limits. Neoadjuvant radiotherapy may result in overtreatment. We aimed to define the minimum local benefit that would have to be postulated for radiotherapy in order to bring a benefit to the overall cohort. We hypothesized that saving radiotherapy as treatment for a subset of patients with high-risk tumors and local recurrences improves the outcome of the overall cohort. We sought to simulate preoperative versus postoperative radiotherapy in theoretical decision analysis model based on published recurrence rates, with overall survival being the primary end point.Computerized literature search for studies published between 1996 and 2011, supplemented by manual review of the retrieved reference lists.Postoperative radiotherapy evolved as preferred strategy with cure rates of 65.6 % vs. 63.7 % for postoperative and neoadjuvant radiotherapy, respectively, and a decrease of radiation exposure to 42.9 % of the cohort. The system was sensitive to (1) the fraction of stage I cancers included in the cohort, (2) the difference between local recurrence rates (LRR) for neoadjuvant radiotherapy, adjuvant radiotherapy, or surgery-only approach, and (3) the compliance with the postoperative radiotherapy. If the surgery-only recurrence was set to the published 10 %, 13 %, and 27 %, respectively, adjuvant radiotherapy had to achieve LRR below the threshold values of 6.3 %, 8.5 %, and 18.3 % to reverse the impact of compliance.Radiotherapy only improves cancer-specific survival of the cohort if there is a large difference in LRR with versus without it. Routine treatment may therefore be inferior to a tailored radiotherapy regimen.

Postoperative outcomes of patients undergoing laparoscopic-assisted colectomy (LAC) have shown modest improvements in recovery but only minimal differences in quality of life (QOL) compared with open colectomy. We therefore sought to assess the effect of LAC on QOL in the short and long term, using individual item analysis of multi-item QOL assessments.QOL variables were analyzed in 449 randomized patients from the COST trial 93-46-53 (INT 0146). Both cross-sectional single-time and change from baseline assessments were run at day 2, week 2, month 2, and month 18 postoperatively in an intention-to-treat analysis using Wilcoxon rank-sum tests. Stepwise regression models were used to determine predictors of QOL.Of 449 colon cancer patients, 230 underwent LAC and 219 underwent open colectomy. Subdomain analysis revealed a clinically moderate improvement from baseline for LAC in total QOL index at 18 months (P = 0.02) as well as other small symptomatic improvements. Poor preoperative QOL as indicated by a rating scale of ≤ 50 was an independent predictor of poor QOL at 2 months postoperatively. QOL variables related to survival were baseline support (P = 0.001) and baseline outlook (P = 0.01).Eighteen months after surgery, any differences in quality of life between patients randomized to LAC or open colectomy favored LAC. However, the magnitude of the benefits was small. Patients with poor preoperative QOL appear to be at higher risk for difficult postoperative courses, and may be candidates for enhanced ancillary services to address their particular needs.