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A low resource setting (LRS) is defined as a health care system which does not meet the criteria defined by the World Health Organization (WHO) or other national/international organizations in the following areas: infrastructure, materials, and human resources.1 Patients encounter barriers which limit their access to care and services that are considered standard of care. While LRS is most commonly associated with developing countries, it is easy to overlook communities in developed countries which lack the financial resources to afford basic health care. This article describes the societal implications and barriers to care for both squamous intraepithelial lesions (SILs) and anal cancer in LRS, the existing screening/surveillance approaches, available treatment approaches to anal cancer, and it also discusses potential evidence-based approaches to bridge the gap for these disparities in anal cancer care.

AIM Emerging evidence has suggested that metformin may be protective against the development of human-papillomavirus-related cancers. Anal intraepithelial neoplasia (AIN) is highly associated with human papillomavirus infection and a precancerous status of anal cancer. The aim of this study was to investigate the relationship between metformin usage and the development of AIN in a large national sample. METHODOLOGY The IBM MarketScan dataset was used to design a nested case-control study from 2010 to 2017. Patients aged 18-65 years with type 2 diabetes mellitus (DM) were evaluated, and cases of AIN were identified. Four controls were randomly selected in the risk set of each case by using incidence density sampling. The association between metformin usage and AIN was assessed using multivariate logistic regression modelling. RESULTS A total of 258 patients with type 2 DM were diagnosed with AIN during the study interval, and these were matched to 1032 control patients without a diagnosis of AIN. Patients who developed AIN had 38% lower odds of prior metformin use compared to those without a history of AIN (P

Despite the general decrease in overall incidence of colorectal cancer since the early 1990s, the incidence of colorectal cancer in patients less than 50 years old has nearly doubled. A systematic review was performed using the PubMed database (2011-2020) and Cochrane Database of Systematic Reviews (2011-2021) to identify studies (published in English) evaluating epidemiologic, clinical, hereditary, and molecular features; as well as evaluation, management, and prognosis of young-onset colorectal cancer patients. Our search yielded a total of 3401 articles, after applying our inclusion criteria. We fully reviewed 94 full-length studies. This systematic review demonstrates the increasing incidence of young-onset colorectal cancer and highlights the importance of being hypervigilant for the differential diagnosis colorectal cancer when evaluating a young adult who presents with gastrointestinal symptoms.

Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have improved as surgeons have become more experienced with this technique. Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016–2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity. A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups. Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.

BACKGROUND Minimally invasive surgical techniques are routinely promoted as alternatives to open surgery because of improved outcomes. However, the impact of robotic surgery on certain subsets of the population, such as frail patients, is poorly understood. OBJECTIVE The purpose of our study was to examine the association between frailty and minimally invasive surgical approaches with colon cancer surgery. DESIGN This is a retrospective study of prospectively collected outcomes data. Thirty-day surgical outcomes were compared by frailty and surgical approach using doubly robust multivariable logistic regression with propensity score weighting, and testing for interaction effects between frailty and surgical approach. SETTING Patients undergoing an open, laparoscopic, or robotic colectomy for primary colon cancer, 2012 to 2016, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Patients undergoing a colectomy with an operative indication for primary colon cancer were selected. MAIN OUTCOME MEASURES The primary outcomes measured were 30-day postoperative complications. RESULTS After propensity score weighting of patients undergoing colectomy, 33.8% (n = 27,649) underwent an open approach versus 34.3% (n = 28,058) underwent laparoscopic surgery versus 31.9% (n = 26,096) underwent robotic surgery. Robotic (OR, 0.53; 95% CI, 0.42-0.69, p < 0.001) and laparoscopic (OR, 0.58; 95% CI, 0.52-0.66, p < 0.001) surgeries were independently associated with decreased rates of major complications. Frailer patients had increased complication rates (OR, 1.56; 95% CI, 1.07-2.25, p = 0.018). When considering the interaction effects between surgical approach and frailty, frailer patients undergoing robotic surgery were more likely to develop a major complication (combined adjusted OR, 3.15; 95% CI, 1.34-7.45, p = 0.009) compared with patients undergoing open surgery. LIMITATIONS Use of the modified Frailty Index as an associative proxy for frailty was a limitation of this study. CONCLUSIONS Although minimally invasive surgical approaches have decreased postoperative complications, this effect may be reversed in frail patients. These findings challenge the belief that robotic surgery provides a favorable alternative to open surgery in frail patients. See Video Abstract at http://links.lww.com/DCR/B163. LOS PACIENTES MAS FRAGILES SOMETIDOS A COLECTOMIA ROBOTICA POR CANCER DE COLON EXPERIMENTAN MAYORES TASAS DE COMPLICACIONES EN COMPARACION CON ABORDAJES LAPAROSCOPICO O ABIERTO: Las tecnicas quirurgicas minimamente invasivas estan frecuentement promovidas como alternativas a la cirugia abierta debido a sus mejores resultados. Sin embargo, el impacto de la cirugia robotica en ciertos subgrupos de poblacion, como el caso de los pacientes endebles, es poco conocido.El proposito de nuestro estudio fue examinar la asociacion entre la fragilidad de los pacientes y el aborgaje quirurgico minimamente invasivo para la cirugia de cancer de colon.Estudio retrospectivo de datos de resultados recolectados prospectivamente. Los resultados quirurgicos a 30 dias se compararon entre fragilidad y abordaje quirurgico utilizando la regresion logistica multivariable doblemente robusta con ponderacion de puntaje de propension y pruebas de efectos de interaccion entre fragilidad y abordaje quirurgico.Los pacientes identificados en la base de datos del Programa Nacional de Mejora de la Calidad Quirurgica del Colegio Estadounidense de Cirujanos, que fueron sometidos a una colectomia abierta, laparoscopica o robotica por cancer de colon primario, de 2012 a 2016.Todos aquellos pacientes seleccionados con indicacion quirurgica de cancer primario de colon que fueron sometidos a una colectomia.Las complicaciones postoperatorias a 30 dias.Luego de ponderar el puntaje de propension de los pacientes colectomizados, el 33.8% (n = 27,649) fue sometido a laparotomia versus el 34.3% (n = 28,058) operados por laparoscopia versus el 31.9% (n = 26,096) operados con tecnica robotica. Las cirugias roboticas (OR 0.53, IC 95% 0.42-0.69, p < 0.001) y laparoscopicas (OR 0.58, IC 95% 0.52-0.66, p < 0.001) se asociaron de forma independiente con una disminucion de las tasas de complicaciones mayores. Los pacientes mas delicados tenian mayores tasas de complicaciones (OR 1.56, IC 95% 1.07-2.25, p = 0.018). Al considerar los efectos de interaccion entre el abordaje quirurgico y la fragilidad, los pacientes mas debiles sometidos a cirugia robotica tenian mas probabilidades de desarrollar una complicacion mayor (OR ajustado combinado 3.15, IC 95% 1.34-7.45, p = 0.009) en comparacion con los pacientes sometidos a cirugia abierta.El uso del indice de fragilidad modificado como apoderado asociativo de la fragilidad.Si bien los abordajes quirurgicos minimamente invasivos han disminuido las complicaciones postoperatorias, este efecto puede revertirse en pacientes labiles. Estos hallazgos desafian la creencia de que la cirugia robotica proporciona una alternativa favorable a la cirugia abierta en pacientes fragiles. Consulte Video Resumen en http://links.lww.com/DCR/B163. (Traduccion-Dr. Xavier Delgadillo).

Objectives Early discontinuation of infliximab (IFX) in pregnant women with inflammatory bowel disease (IBD) decreases the intrauterine fetal exposure to the drug but may increase the risk of disease flaring leading to poor pregnancy outcomes. In this study, we assessed the impact of early IFX discontinuation on mother’s disease activity and on their at-risk babies. Methods In a retrospective study of the Truven Health Analytics MarketScan database from 2011 to 2015, we compared IBD patients who discontinued IFX more than 90 days (“early IFX”) with those who discontinue IFX 90 days or less (“late IFX) before delivery. We evaluated the risk of flaring, defined by new steroid prescriptions, visits to emergency room and/or hospital admissions, the pregnancy outcomes, and the at-risk babies. Results After IFX discontinuation, the early IFX group (68 deliveries) required significantly more steroid prescriptions than the late IFX group (318 deliveries) to control disease activity (P < 001). There were more preterm babies in the early IFX group (P < 049), but no difference within the 2 groups was noticed in the rate of intrauterine growth retardation, small for gestation, and stillborn babies. Similarly, there was no increase in acute respiratory infections, development delays, and congenital malformations in babies of the mothers from the late IFX vs early IFX groups. Conclusions Steroid-free remission IBD mothers are at risk for disease flares and preterm babies when IFX is discontinued early in pregnancy. Continuation of IFX seems to be safe at least for the first year of life.

Background: Anal cancer incidence is increasing in the US. Though formally established national anal cancer screening guidelines are nonexistent, many providers advocate screening to avoid late disease presentation. This study assesses the knowledge, attitudes, and practices of anal cancer screening among providers to identify the degree of variation and barriers to screening. Methods: Healthcare providers from two academic medical centers and a statewide community primary care group were surveyed using a questionnaire adapted from the National Survey of Primary Care Physicians’ Recommendations and Practice for Cancer Screening. Descriptive statistics were performed to explore providers’ responses and Fisher’s exact test to explore variation. Results: 86 providers completed the questionnaire (response rate 24.2%): 81.4% physicians, 18.6% advanced practitioners. 48.2% of respondents perform anal cancer screening. 5.8% correctly identified all high-risk patient factors. “HIV+ patient” was identified most frequently as high-risk (93.5%), “organ transplant recipient” (42.9%) least frequently. Anal pap test was the most recommended first-line screening test (76.6%) followed by digital anorectal exam (19.2%), HPV test (8.5%), and high-resolution anoscopy (HRA) (6.4%). Clinical evidence (72.3%) and national guidelines (70.2%) were most influential in guiding providers’ screening recommendations. Lack of qualified screening providers (34.1%), lack of patient follow-up after positive test results (22.7%), and patient non-compliance to initial screening (15.9%) were identified as “usual” barriers. Conclusions: Anal cancer screening attitudes and practices vary among providers. Development of national practice guidelines that define a multidisciplinary team approach from primary care anal cancer screening to specialist referral for HRA may reduce screening variability.

Increasing evidence supports immediate colectomy in acute fulminant ulcerative colitis in comparison with ongoing medical management. Prior studies have been limited to inpatient-only administrative data sets or single-institution experiences.The purpose of this study was to compare outcomes of early versus delayed emergency colectomy in patients admitted with ulcerative colitis flares while controlling for known preoperative risks and acuity.This is a cohort study of patients undergoing emergent total abdominal colectomies for ulcerative colitis compared by the timing of surgery.Adult patients undergoing an emergent total abdominal colectomy for ulcerative colitis, 2005 to 2015, were identified in the American College of Surgeons National Surgical Quality Improvement Program database.Patients undergoing total abdominal colectomy with an operative indication of ulcerative colitis admitted on a nonelective basis were selected.The primary outcomes measured were 30-day National Surgical Quality Improvement Program-reported mortality and postoperative complications, and early operation within 2 days of admission.We identified 573 total abdominal colectomies after propensity score matching. Median time to surgery was 1 hospital day in the early group versus 6 hospital days in the delayed group (p0.001). Early operation was associated with a lower mortality rate (4.9% versus 20.3% in matched groups, p0.001) and lower complication rate (64.5% versus 72.0%, p = 0.052). Multivariable logistic regression with propensity weighting of mortality on preoperative risk factors demonstrated that early surgery is associated with an 82% decrease in the odds of death compared with delayed surgery (p0.001). Regression of morbidity on preoperative risk factors demonstrated that early surgery is associated with a 35% decrease in the odds of a complication with delayed surgery (p = 0.034).Quality improvement data were used for clinical research questions.Patients undergoing immediate surgical intervention for acute ulcerative colitis have decreased postoperative complications and mortality rates. Rapid and early transitioning from medical to surgical management may benefit those expected to require surgery on the same admission. See Video Abstract at http://links.lww.com/DCR/A800.

Background The development of high-resolution anoscopy (HRA) has advanced our ability to detect anal dysplasia. Historically, HRA is performed in a clinical setting and subsequent ablation is performed in the clinical setting or operating room. The aim of this study was to determine the most effective venue for the performance of HRA. Methods Following institutional review board (IRB) approval, the correlation between anal cytology and HRA performed in the clinic versus in the operating room was evaluated. Data were extracted from our IRB-approved prospective HRA database over the time period of 2013–2017. Results One hundred twenty-eight HRAs were compared (101 in the clinical setting, 27 in the operating room). There was a statistically significant difference in the correlation between anal cytology and HRA pathology for procedures performed in the clinical setting (55% [56/101]) versus those performed in the operating room (82% [22/27]) (p = 0.014). More biopsies were obtained in the operating room than in the clinic setting (3 vs. 1, p Conclusions Detection rates for anal dysplasia on HRA, are significantly higher when performed in the operating room. To prevent discomfort in the clinical setting, patients with high-grade dysplasia on anal pap testing may benefit from proceeding directly to the operating room for concurrent HRA and ablation.

Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have improved as surgeons have become more experienced with this technique.Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016-2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity.A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups.Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.

Frailty and functional dependence are important factors in assessing preoperative risk. No studies to date have compared frailty with functional dependence as a predictor of surgical outcomes. We sought to compare the impact of frailty and functional dependence on early outcomes after gastrointestinal surgery.Patients who underwent gastrointestinal surgery were identified using the American College of Surgeons National Surgical Quality Improvement Program database (2012-2015). Propensity score matching analysis was used to separately match dependent and independent patients, and patients with modified frailty index3 and modified frailty index ≥3 on baseline characteristics. Multivariable logistic regression analysis was used. Postoperative outcomes were compared.Of 765,082 patients, 1.71% were dependent and 1.49% had a modified frailty index score ≥3. Similar outcomes were observed in matched cohorts for those who were dependent and patients with a modified frailty index score ≥3: readmission (15.61% dependent and 15.75% modified frailty index ≥3), overall morbidity (37.91% and 34.81%), serious morbidity (19.06% and 17.06%), mortality (6.73% and 5.43%), and reoperation (7.01% and 6.48%). Dependent and modified frailty index ≥3 patients had similar odds of outcomes on adjusted multivariable logistic analysis and shared 3 of the top 5 indicators for readmission: complication of surgical procedure (11.46% dependent and 11.23% mFI ≥3), intestinal obstruction (10.70% and 7.65%), and organ space surgical site infection (7.93% and 8.65%). Comparable outcomes and reasons for readmission were also obtained for dependent patients and colectomy patients with a modified frailty index score ≥3.Frailty and functional dependence are comparable in predicting postoperative outcomes after gastrointestinal surgery. Functional dependence should be considered an acceptable and practical alternative for preoperative risk stratification in a clinical setting.

An area of contention among colorectal surgeons is when it is safe to discharge patients who have undergone closure of diverting ostomies. This study aimed to review the trends in outpatient stoma closure (OSC), to assess the safety of this practice, and to identify appropriate surgical candidates for the outpatient procedure.Patients were queried from the ACS National Surgical Quality Improvement Program database (2005-2016). Main outcomes included Clavien-Dindo (C-D) III-V class surgical complications, and readmission. Outpatient stay was defined as a hospital stay of less than or equal to 1 day. Multivariable logistic regression analysis was used to identify risk factors for C-D III-V complications and readmission.Of 24,393 patients, 668 (2.74%) underwent an OSC. OSC has increased over the last decade (3.16% 2005-2006, 4.14% 2016, p 0.001). Outpatients had significantly lower ASA class and fewer comorbidities than inpatients. Outpatient complication rate was significantly lower than the inpatient rate (2.99% vs. 7.25%, p 0.001). Readmissions were comparable (8.92% outpatient vs. 9.77% inpatient, p = 0.54). ASA 2, smoking, COPD, dyspnea, steroid use, bleeding disorder, and partial/total dependency were associated with increased risk of complications and readmission. Patients without any risk factors had lower complication (4.75%) and readmission rates (8.09%) compared to those with ≥ 2 risk factors (11.50% complication and 13.07% readmission rate, p 0.001).There is an increasing trend in the percentage of stoma closures being performed as outpatient procedures. Appropriate selection of patients preoperatively who are suitable candidates for OSC can be helpful in managing patient expectations and hospital resources.

A 63-year-old man presents to his primary care doctor with a one-month history of blood in his stools. He is referred for a colonoscopy and found to have a friable mass along the anterior wall just proximal to the second rectal fold. A biopsy confirms moderately-differentiated adenocarcinoma. The patient then obtains pelvic magnetic resonance imaging and chest, abdomen, and pelvis computed tomography demonstrating local invasion of the primary tumor into the mesorectal fat (T3), no suspicious regional lymph nodes (N0), and no evidence of distant metastatic disease (M0).

Background In inflammatory bowel disease (IBD), many scenarios call for fecal diversion, leaving behind defunctionalized bowel. The theoretical risk of colorectal cancer (CRC) in this segment is frequently cited as a reason for resection. To date, no studies have characterized the incidence of neoplasia in the diverted colorectal segments of IBD patients. Methods A retrospective cohort analysis was conducted for IBD patients identified through a tertiary care center pathology database. Patients that had undergone colorectal diversion and were diverted for ≥ 1 year were included. Incidence of diverted dysplasia/CRC was calculated for Crohn’s disease (CD) and ulcerative colitis (UC) with respect to diverted patient-years (dpy) and patient-years of disease (pyd). Results In total, 154 patients comprising 754 dpy and 1984 pyd were analyzed. Only 2 cases of diverted colorectal dysplasia (CD 1, UC 1) and 1 case of diverted CRC (UC) were observed. In the UC cohort (n = 75), the rate of diversion-associated CRC was 4.5 cases/1000 dpy (95% CI 0.11–25/1000) or 1.5 cases/1000 pyd (95% CI 0.04–8.2/1000). In the CD cohort (n = 79), no patients developed CRC, although a dysplasia rate of 1.9 cases/1000 dpy (95% CI 0.05–11/1000) or 0.77 cases/1000 pyd (95% CI 0.02–4.3/1000) was observed. All patients developing neoplasia had disease duration > 10 years and microscopic inflammation. Conclusions Diverted dysplasia occurred infrequently with rates overlapping those reported in registries for IBD-based rectal cancers. Neoplasia was undetected in patients with < 10 pyd, regardless of diversion duration, suggesting low yield for endoscopic surveillance before this time.

BACKGROUND: The incidence of squamous cell carcinoma (SCC) of the anal canal has been rising over the past decades, especially in patients infected with human immunodeficiency virus (HIV). Despite the advent of potent multidrug regimens to treat HIV-termed highly active antiretroviral therapy (HAART), anal SCC rates have not declined, and the impact of HAART on anal SCC remains controversial. AIM: The purpose of this study was to define outcomes of anal SCC treatment in HIV-positive and HIV-negative patients. METHODS AND MATERIALS: A retrospective single-institution analysis was performed on all patients with anal SCC treated at the Johns Hopkins Hospital between 1991 and 2010. The primary outcomes measured were 5-year overall survival (5-year OS), median survival, and relapse rates. RESULTS: Our search identified 93 patients with anal SCC. Patients had a mean age of 54 years; 37.6% were male, and 21.5% were HIV-positive. Median follow-up was 28 months. Relapse occurred in 16.1% of patients. Median time to relapse was 20 months. Relapse rates were slightly higher with HIV-positive versus negative patients (30.0 vs.12.3%) but did not reach statistical significance (p = 0.06). Among HIV-positive patients, those who relapsed were more likely to be on HAART than those who did not relapse (83.3 vs. 14.3%, p = 0.007). 5-year OS was 58.9% for the total group of patients with no significant difference between those who relapsed versus those who did not (76.2 vs. 54.5%, p = 0.20). No survival difference was seen between HIV-positive and negative patients. Survival was associated with AJCC stage in all patients. CONCLUSION: In our small series, HIV infection was not associated with a significantly higher relapse rate or worse 5-year OS among patients with anal SCC. HAART was associated with a higher rate of relapse in HIV-positive patients. AJCC staging predicted survival in both relapsed and non-relapsed patients regardless of HIV status.

Timing of surgical intervention for acute ulcerative colitis has not been fully examined during the modern immunotherapy era. Although early surgical intervention is recommended, historical consensus for "early" ranges widely. The purpose of this study was to evaluate outcomes according to timing of urgent surgery for acute ulcerative colitis.All non-elective total colectomies in ulcerative colitis patients were identified in the National Inpatient Sample from 2002 to 2014. Procedures, comorbidities, diagnoses, and in-hospital outcomes were collected using International Classification of Disease, 9th Revision codes. An operation was defined as early if within 24 hours of admission. Results were compared between the early versus delayed surgery groups.We found 69,936 patients that were admitted with ulcerative colitis, and 2650 patients that underwent non-elective total colectomy (3.8%). Early intervention was performed in 20.4% of patients who went to surgery. More early operations were performed laparoscopically (28.1% versus 23.3%, p = 0.021) and on more comorbid patients (Charlson Index, p = 0.008). Median total hospitalization costs were $20,948 with an early operation versus $33,666 with a delayed operation (p 0.001). Delayed operation was an independent risk for a complication (OR = 1.46, p = 0.001). Increased hospitalization costs in the delayed surgery group were statistically significantly higher with a reported complication (OR = 3.00, p 0.001) and lengths of stay (OR = 1.26, p 0.001).Delayed operations for acute ulcerative colitis are associated with increased postoperative complications, increased lengths of stay, and increased hospital costs. Further prospective studies could demonstrate that this association leads to improved outcomes with immediate surgical intervention for medically refractory ulcerative colitis.

Background: Creation of a J pouch is the gold standard surgical intervention in the treatment of chronic ulcerative colitis (UC). Pouchoscopy prior to ileostomy takedown is commonly performed. We describe the frequency, indication, and findings on pouchoscopy, and determine if pouchoscopy affects rates of complications after takedown. Methods: All UC or indeterminate inflammatory bowel disease patients with a J pouch were retrospectively evaluated from January 1994 to December 2014. Cases were defined as having routine (asymptomatic) pouchoscopy after pouch creation but before ileostomy takedown. Controls were defined as having no pouchoscopy or pouchoscopy on the same day as that of takedown. Results: The study included 178 patients (81.5% cases, 18.5% controls). Fifty two percent of pouchoscopies were reported as normal. Common abnormal endoscopy findings included stricture (35%), pouchitis (7%), and cuffitis (0.7%). Length of stay during takedown hospitalization was shorter for cases than controls (3 vs. 5 days; p = 0.001), but neither short- nor long-term complications were statistically different between cases and controls. Abnormalities on pouchoscopy were not predictive for short-term complications (p = 0.73) or long-term complications (p = 0.55). Routine pouchoscopy did not delay takedown surgery in any of the included patients. Conclusions: Routine pouchoscopy may not be necessary prior to ileostomy takedown; its greatest utility is in patients with suspected pouch complications.

Background There is continued debate regarding the optimal combinations of radiation therapy and chemotherapy in the preoperative treatment of locally advanced rectal adenocarcinomas. We report our single-institution experience of feasibility and early oncologic outcomes of short-course preoperative radiation therapy (5 Gy X 5 fractions) followed by consolidation neoadjuvant chemotherapy. Methods We reviewed the records of 26 patients with locally advanced rectal adenocarcinoma. All patients underwent short course radiotherapy (5 Gy X 5 fractions) followed by chemotherapy [either modified infusional and bolus 5-fluorouracail and oxalipatin (mFOLFOX6) or capecitabine and oxaliplatin] prior to consideration for surgery. A full course of chemotherapy was defined as at least 8 weeks of chemotherapy. Results There were five clinical (c) T2, 16 cT3, and five cT4 rectal tumors, with 88% cN+. Twenty-five patients received a median of 4 cycles (range 3 to 8) of mFOLFOX6 (with one cycle defined as a two-week period); one patient received 3 cycles of capecitabine and oxaliplatin. All patients completed SCRT; 81% completed the full course of neoadjuvant chemotherapy with 19% requiring dose reductions in chemotherapy, most commonly due to neuropathy. Nineteen patients underwent post-treatment endoscopic evaluation, and nine patients were noted to achieve a complete clinical response (CCR). Six of the nine patients who achieved CCR opted for a non-operative approach of watch-and-wait. Twenty patients underwent surgical resection; pathologic complete response was observed in seven (35%) of these twenty. The main radiation-associated toxicity was proctitis with CTCAE Grade 2 proctitis observed in seven patients (27%). Post-operative Clavien-Dindo Grade 3 complications within 30 days of surgery were identified in six patients (30%), with no Grade 4 or 5 adverse events. Median length of hospital stay was 4.5 days (range 2–16 days); three patients were readmitted within a 30 day period. Conclusions Short course preoperative radiotherapy followed by neoadjuvant chemotherapy was well-tolerated and achieved oncologic outcomes that compare favorably with short-course radiation therapy alone or long-course chemoradiotherapy. This regimen is associated with high rates of clinical and pathologic complete response.

Readmission has received attention as a potential healthcare quality metric. No studies have investigated the relationship between readmission and survival in patients undergoing rectal cancer surgery. The aims of this study were to identify factors associated with 30-day readmission after rectal cancer surgery and to determine the impact of readmission on overall survival (OS). Patients who underwent surgical treatment for rectal/rectosigmoid adenocarcinoma stages I–IV were identified using the National Cancer Database (2004–2014). Multivariable logistic regression was used to identify factors for readmission. 2:1 nearest neighbor caliper matching without replacement was used to ensure similarity of patients being compared. Survival analyses were performed using Kaplan–Meier method along with log-rank test and Cox proportional hazards model. Of 110,167 patients, 7045 (6.39%) were readmitted. Factors associated with readmission included higher Charlson comorbidity score, non-private or no insurance, procedure type, hospitals in the Northeast, South, and Midwest regions, and prolonged length of stay. Within the matched cohort (13,756 non-readmitted and 6878 readmitted), readmitted patients had worse 5- and 10-year OS regardless of cancer stage (p

The aim of this study is to assess treatment trends and overall survival (OS) in small bowel (SB) and colorectal (CR) gastrointestinal stromal tumors (GIST) with respect to the introduction of imatinib in 2008. Patients diagnosed with SB and CR GIST were identified from the National Cancer Database (2004–2015). The primary outcome was 5- and 10-year OS. Patients were stratified by tumor site, time period (before and after imatinib), and treatment type. OS was analyzed using Kaplan-Meier survival curves, log-rank test, and Cox proportional hazards models. A total of 8441 cases were included (SB 81.66%; CR 18.34%). Radical resection was the most common treatment (SB 42.33%; CR 38.69%). The addition of chemotherapy to radical resection for SB GIST increased between the two time periods (31.76 to 40.43%; p

Immunotherapy advances for the treatment of cutaneous melanoma question its efficacy in treating anorectal mucosal melanoma (ARMM). We aimed to identify the prevalence, current management, and overall survival (OS) for ARMM. Review of patients with ARMM from 2004 to 2015 National Cancer Database. Factors associated with immunotherapy were identified using multivariable logistic regression. The primary outcome was 2- and 5-year OS. Subgroup analysis by treatment type was performed. A total of 1331 patients were identified with a significant increase in prevalence (2004: 6.99%, 2015: 10.53%). ARMM patients were older, white, on Medicare, and from the South. The most common treatment was surgery (48.77%), followed by surgery + radiation (11.75%), surgery + immunotherapy (8.68%), and surgery + chemotherapy (8.68%). 16.93% of patients received immunotherapy, with utilization increasing (7.24%: 2004, 21.27%: 2015, p

AIM The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing. METHOD The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence. RESULTS A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P

Adenocarcinoma is a rare finding following urinary diversion with gastrointestinal segments. This report describes an 80-year-old woman with a history of bladder cancer who subsequently developed a pT4 adenocarcinoma 8 years following her radical cystectomy and Indiana Pouch continent urinary diversion. An en bloc resection of the pouch and affected small bowel was performed and the patient underwent conversion to an ileal conduit diversion. We use this case to highlight a mechanism for possible pathogenesis and the management of adenocarcinoma in urinary diversions including the need for regular surveillance and the surgical approach.

A thorough understanding of anal cancer necessitates a nuanced comprehension of the anatomy involved. The anal canal and sphincter complex are often oversimplified, but the alternative perspectives on this anatomic region and its histologic characteristics influence how anal cancer pathology is conceptualized and ultimately treated. In this chapter, we highlight the divergent definitions and complexity of anal canal anatomy, review the anatomic and functional configuration of the pelvic floor and anal sphincter musculature, delineate histologic characteristics of the anal canal and perianal skin, and describe the distinct vascular and lymphatic drainage patterns of the anal canal and perianal skin.

A thorough understanding of anatomy is essential to the mastery of gastrointestinal surgery. In this chapter, the anatomy is outlined in parallel to critical steps in major colorectal procedures. References to newer methods of imaging to guide the surgeon during these steps are also included. It is our hope that this chapter provides you with a greater appreciation of colorectal anatomy.

Background All-cause readmission rates in patients undergoing ileostomy formation are as high as 20% to 30%. Dehydration is a leading cause. No predictive model for dehydration readmission has been described. Objective The purpose of this study was to develop and validate the Dehydration Readmission After Ileostomy Prediction scoring system to predict the risk of readmission for dehydration after ileostomy formation. Design Patients who underwent ileostomy formation were identified using the American College of Surgeons National Surgical Quality Improvement Program data set (2012-2015). Predictors for dehydration were identified using multivariable logistic regression analysis and translated into a point scoring system based on corresponding β-coefficients using 2012-2014 data (derivation). Model discrimination was assessed with receiver operating characteristic curves using 2015 data (validation). Settings This study used the American College of Surgeons National Surgical Quality Improvement Program. Patients A total of 8064 (derivation) and 3467 patients (validation) were included from the American College of Surgeons National Surgical Quality Improvement Program. Main outcome measures Dehydration readmission within 30 days of operation was measured. Results A total of 8064 patients were in the derivation sample, with 2.9% (20.1% overall) readmitted for dehydration. Twenty-five variables were queried, and 7 predictors were identified with points assigned: ASA class III (4 points), female sex (5 points), IPAA (4 points), age ≥65 years (5 points), shortened length of stay (5 points), ASA class I to II with IBD (7 points), and hypertension (9 points). A 39-point, 5-tier risk category scoring system was developed. The model performed well in derivation (area under curve = 0.71) and validation samples (area under curve = 0.74) and passed the Hosmer-Lemeshow goodness-of-fit test. Limitations Limitations of this study pertained to those of the American College of Surgeons National Surgical Quality Improvement Program, including a lack of generalizability, lack of ileostomy-specific variables, and inability to capture multiple readmission International Classification of Diseases, 9/10 edition, codes. Conclusions The Dehydration Readmission After Ileostomy Prediction score is a validated scoring system that identifies patients at risk for dehydration readmission after ileostomy formation. It is a specific approach to optimize patient factors, implement interventions, and prevent readmissions. See Video Abstract at http://links.lww.com/DCR/A746.

High volume hospitals (HVHs) and high volume surgeons (HVSs) have better outcomes after complex procedures, but the association between surgeon and hospital volumes and patient outcomes is not completely understood. Our aim was to evaluate the impact of surgeon and hospital volumes, and their interaction, on postoperative outcomes and costs in patients undergoing pelvic exenteration (PE) in the state of Maryland. A review of the Maryland Health Services Cost Review Commission database between 2000 and 2011 was performed. Patients were compared for demographics and clinical variables. The differences in length of hospital stay, length of intensive care unit (ICU) stay, operating room (OR) cost, and total cost were compared for surgeon volume and hospital volume controlling for all other factors. Surgery performed by HVS at HVH had the shortest ICU stay and lowest OR cost. When PE was performed by a low volume surgeon at an HVH, the OR cost and total cost were the highest and increased by $2,683 ( P < 0.0001) and $16,076 ( P < 0.0001), respectively. OR costs reduced when surgery was performed by an HVS at an HVH ($-1632, P = 0.008). PE performed by HVS at HVH is significantly associated with lower OR costs and ICU stay. We feel this is indicative of lower complication rates and higher quality care.

Although previous studies have examined frailty as a potential predictor of adverse surgical outcomes, little is reported on its application. We sought to assess the impact of the 5-item modified frailty index (mFI) on morbidity in patients undergoing combined colorectal and liver resections. Adult patients who underwent combined colorectal and liver resections were identified using the ACS-NSQIP database (2005–2015). The 5-item mFI consists of history of chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, and partial/total dependence. Patients were stratified into three groups: mFI 0, 1, or ≥ 2. The impact of the mFI on primary outcomes (30-day overall and serious morbidity) was assessed using multivariable logistic regression. Subgroup analyses by age and hepatectomy type was also performed. A total of 1928 patients were identified: 55.1% with mFI = 0, 33.2% with mFI = 1, and 11.7% with mFI ≥ 2. 75.9% of patients underwent wedge resection/segmentectomy (84.6% colon, 15.4% rectum), and 24.1% underwent hemihepatectomy (88.8% colon, 11.2% rectum). On unadjusted analysis, patients with mFI ≥ 2 had significantly greater rates of overall and serious morbidity, regardless of age and hepatectomy type. These findings were consistent with the multivariable analysis, where patients with mFI ≥ 2 had increased odds of overall morbidity (OR 1.41, 95% CI 1.02–1.96, p = 0.037) and were more than twice likely to experience serious morbidity (OR 2.12, 95% CI 1.47–3.04, p

Risk-adjusted institutional transfusion rates are not currently available on a national level. A surrogate means of benchmarking transfusion practices to use for internal quality improvement was studied. Blood utilization was prospectively studied among all colorectal surgery patients at the study institution (July 2010-November 2012), and these data were benchmarked with transfusion data from the National Surgical Quality Improvement Program (NSQIP) database by hospital type and size. Using NSQIP, the study institution's colorectal surgery transfusion rate was 16.3% (150/920 cases), which was slightly higher than the 14.3% national mean transfusion rate (12 191/85 507 cases; P = .08). When broken down by hospital type and size, the study hospital had a similar rate of blood transfusion compared with academic hospitals (P = .35) but a significantly higher rate than community hospitals, regardless of patient volume (P = .03). Benchmarking blood utilization compared with similar-type hospitals using NSQIP may be a surrogate method to assess adherence to evidence-based transfusion guidelines and identify areas for structured quality improvement initiatives.

Laparoscopic Hartmann’s reversal is more commonly performed in an open fashion. However, there are selected patients who are excellent candidates for a laparoscopic approach. Surgeon preference usually dictates their comfort level for whether or not this procedure is performed laparoscopically. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis and diverting loop ileostomy is performed for ulcerative colitis refractory to medical management and patients with familial polyposis syndromes. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

The indication for laparoscopic total proctocolectomy with end ileostomy is similar as that for the open version. It is performed for ulcerative or Crohn’s colitis refractory to medical management or for familial polyposis syndromes, when sphincter preservation is not desired or not feasible. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Ligation of intersphincteric tract, also known as the LIFT procedure, is a surgical option for anal fistulas that have been refractory to prior surgical management. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Full-thickness transanal excision is an acceptable alternative to proctectomy for small, benign masses or early-stage cancers in the rectum. Surgical approaches include a traditional, open transanal excision, transanal endoscopic surgery (TEM), or transanal minimally invasive surgery (TAMIS). TAMIS is the most recently developed method and utilizes either a single-incision laparoscopic surgery (SILS) port or a GelPOINT path transanal access platform to insufflate the rectum and excise the lesion using laparoscopic instruments. Advantages of both TEM and TAMIS over the traditional approach include better visualization and overall precision, especially for more proximal lesions. Advantages of TAMIS over TEM include disposable equipment, use of widely available laparoscopic instruments, shorter learning curve, and overall lower cost. Due to the relatively recent advent of this technique, there are not yet long-term outcome data for comparison. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Sacral nerve stimulation (SNS) is a therapeutic option for patients with fecal incontinence who have failed other treatment modalities. The procedure is generally divided into two stages. In Stage 1, a quadripolar lead is positioned in the S3 foramen and tested with a temporary stimulator. If the patient experiences over 50 % improvement of symptoms during a 2-week trial period, the temporary stimulator is exchanged for a subcutaneously implanted permanent one. This chapter describes indications, essential steps, variations, and complications of both stages of the procedure.

Laparoscopic ventral mesh rectopexy (LVMR) is a technique that was developed by D’Hoore et al. for repair of rectal prolapse. The purported advantage of this approach over more traditional methods is that it avoids posterolateral mobilization of the rectum and therefore reduces the likelihood of a neural injury to the pelvic plexus or hypogastric nerves, as well as injury to the sacral venous plexus. In a recent multi-institutional study led by D’Hoore, 919 patients who underwent LVMR were retrospectively reviewed. In this group, rate of recurrence for external rectal prolapse at 10 years was 8.2 %, and rate of mesh erosion at 10 years was 1.3 %. The authors contend that LVMR is safe and effective as a treatment of rectal prolapse. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Treatment of an anal transsphincteric fistula is usually approached by a two-stage procedure. First, a seton is placed for adequate drainage of the anal fistula and is left in place for at least 3 months. Endorectal mucosal advancement flap is a second-stage option for definitive surgical management for fistula-in-ano. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

The Altemeier procedure is a surgical option for rectal prolapse, particularly in high-risk surgical candidates. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Laparoscopic low anterior resection is performed for rectal adenocarcinoma up to 6 cm from anal verge. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Background The incidence of anal cancer in human immunodeficiency virus (HIV)-positive individuals is increasing, and how co-infection affects outcomes is not fully understood. This study sought to describe the current outcome disparities between anal cancer patients with and without HIV undergoing abdominoperineal resection (APR). Methods A retrospective review of all US patients diagnosed with anal squamous cell carcinoma, undergoing an APR, was performed. Cases were identified using a weighted derivative of the Healthcare Utilization Project’s National Inpatient Sample (2000–2011). Patients greater than 60 years old were excluded after finding a skewed population distribution between those with and without HIV infection. Multivariable logistic regression and generalized linear modeling analysis examined factors associated with postoperative outcomes and cost. Perioperative complications, in-hospital mortality, length of hospital stay, and hospital costs were compared for those undergoing APR with and without HIV infection. Results A total of 1725 patients diagnosed with anal squamous cell cancer undergoing APR were identified, of whom 308 (17.9 %) were HIV-positive. HIV-positive patients were younger than HIV-negative patients undergoing APR for anal cancer (median age 47 years old versus 51 years old, p