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Introduction: Low Anterior Resection Syndrome (LARS) describes bowel dysfunction post-restorative proctectomy (RP) and is associated with poor quality of life (QoL). The aim of this study was to assess the impact of an interactive online informational and peer support App on participants' QoL (primary outcome), LARS, and emotional distress (secondary outcomes)., Methods: A multicentre, randomized, parallel-group trial was conducted across five Canadian colorectal surgery practices. Adult patients who: (1) underwent RP for rectal cancer and completed all treatment and (2) had major/minor LARS were included. Participants were randomized in a 1:1 ratio to treatment or comparison group, stratified by hospital site and years post-RP. The treatment group had access to the App for a period of 6 months, and the comparison group received a booklet containing the same educational material as the App. The primary outcome was change in global QoL (EORTC-QLQ-C30) from baseline to 6 months post-intervention. Per-protocol and intention to treat analysis were performed, controlling for a priori selected variables (sex, time from end of treatment)., Results: Of the 101 enrolled participants, 10 individuals were lost to follow-up and 91 completed the study. Participants were well-balanced in terms of baseline characteristics, QoL and bowel dysfunction. Among the 45 App users, median log-in per person was 21, with 30 (66.7%) participants meeting criteria for adequate app usage. On intention to treat analysis, there was no statistically significant difference in QoL in the App group. On the per-protocol analysis, where only participants who met adequate App usage criteria were included in the treatment group, the group reported statistically significant improvement in QoL (β 9.5, 95% CI 4.6,14.6) and LARS (β - 2.7, 95%CI - 5.1,- 0.2) scores following App usage., Conclusion: This multicenter randomized controlled trial support that, when adequately used, an interactive online informational and peer support App has the potential to improve QoL of rectal cancer survivors living with LARS post-RP., Competing Interests: Declarations. Disclosures: Drs. Jeongyoon Moon, Olivia Monton, Allister Smith, Richard Garfinkle, Carl Brown, Martha Chamdroka, Erin Kennedy, Carol-Ann Vasilevsky, Julio Fiore, Carmen Loiselle, Phyllis Zelkowitz, Sahir Bhatnagar, Marie Demian, Sarah Sabbobeh, and Julie Savard have no conflicts of interest or financial ties to disclose. Dr. Marylise Boutros received teaching honorarium from Ethicon Johnson and Johnson. Dr. Sami Chadi received consulting and speaking honoraria for Stryker Endoscopy. Dr. Sender Liberman received speaking honoraria from Abbott Nutrition and research funding from Takeda. Consent to participate: The study was an oral presentation at the SAGES Annual Scientific Meeting, April 17-20,2024, in Cleveland, Ohio, USA., (© 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Non-antibiotic outpatient treatment of acute uncomplicated diverticulitis is safe; however, uptake remains low., Objective: To assess the success of non-antibiotic management of uncomplicated diverticulitis through a nurse clinician-led outpatient program., Design: Retrospective audit from June 2022-March 2024., Settings: Nurse clinician-led outpatient program for non-antibiotic management of acute uncomplicated diverticulitis at a university-affiliated hospital., Patients: Immunocompetent adults with CT-proven acute uncomplicated diverticulitis and C-reactive protein <150 mg/L. Eligible patients not referred to the program but treated in the Emergency Department during the same time period were also reviewed., Interventions: This program included education, diet modification, analgesia, clinic visit, and telephone follow-ups by a nurse-clinician., Main Outcome Measures: Primary outcome was success of the program, defined as the proportion not requiring an Emergency Department visit, admissions within 60 days of diagnosis or need for antibiotics., Results: Of 236 patients referred to the program, 84 met inclusion criteria, of which 43 (51.2%) were started on antibiotics before referral but were treated by the program. Forty-one (48.8%) completed the non-antibiotic protocol (48.8%, n = 41), with 97.6% success. Concurrently, 219 eligible patients were treated in the Emergency Department but not referred to the program. There was no difference in the number of Emergency Department visits between the 2 groups [program: n = 7 (8.3%) vs Emergency Department: n = 27 (12.3%)] within 60 days of diagnosis. Two patients (2.3%) treated in the program required admission, while 7 (3.2%) patients in the Emergency Department group were admitted. Overall, antibiotics were started before referral in 51.2% of patients in the program compared to 92.2% in the Emergency Department (p < 0.005)., Limitations: Modest sample size, single institutional data and retrospective design., Conclusions: Implementation of non-antibiotic treatment for mild acute uncomplicated diverticulitis can be successful using an outpatient nurse-clinician led program with referrals from the Emergency Department and community. See Video Abstract., (Copyright © The ASCRS 2024.)

Aim: Sexual dysfunction is an important, and often overlooked, sequela of rectal cancer treatment with significant implications for patients' quality of life. The aim of this study was to explore patients' information needs regarding sexual health after rectal cancer treatment and their experiences accessing information on sexual dysfunction throughout the cancer care continuum. The secondary aim was to explore surgeons' perspectives on patients' information needs and gain insight into their experiences providing information on sexual health following rectal cancer surgery., Method: A qualitative study was conducted using semistructured interviews with 10 rectal cancer survivors and six colorectal surgeons from a Canadian tertiary care institution. Transcribed interviews were coded independently by two researchers and thematic analysis was performed., Results: Analysis of patient interviews revealed that patients had limited knowledge of sexual dysfunction symptoms following rectal cancer treatment and received inadequate information on sexual dysfunction from their treating medical team. Patients expressed the desire to receive information on sexual dysfunction in different formats, especially before the start of treatment. The surgeon interviews revealed that colorectal surgeons faced challenges when informing patients about sexual dysfunction. Surgeons did not routinely provide information on sexual dysfunction to all patients; however, they felt that patients should receive high-quality information on sexual dysfunction, both before and after treatment., Conclusion: Patients' information needs related to sexual dysfunction after rectal cancer treatment were inadequately met. High-quality informational resources are needed to facilitate communication between patients and physicians and improve patients' understanding of sexual dysfunction., (© 2024 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background and Purpose: Emergency colectomies are associated with a higher risk of complications compared to elective ones. A critical assessment of complications occurring beyond post-operative day 30 (POD30) is lacking. This study aimed to assess the readmission rate and factors associated with readmission 6-months following emergency colectomy., Methods: A retrospective cohort study of adult patients who underwent emergency colectomy (2010-2018) was performed using the Nationwide Readmissions Database. The cohort was divided into two groups: (i) no readmission and (ii) emergency readmission(s) for complications related to colectomy (defined using ICD-9/10 codes). Readmissions were categorized as either "early" (POD0-30) or "late" (> POD30). Differences between groups were described and multivariable regression controlling for relevant covariates defined a priori were used to identify factors associated with timing of readmission and cost., Results: Of 141,481 eligible cases, 13.22% (n = 18,699) were readmitted within 6-months of emergency colectomy for colectomy-related complications, 61.63% of which were "late" readmissions (> POD30). The most common reasons for "late" readmission were for bleeding, gastrointestinal, and infectious complications (20.80%, 25.30%, and 32.75%, respectively). On multiple logistic regression, female gender (OR 1.12; 95%CI 1.04-1.21), open procedures (OR 1.12, 95%CI 1.011-1.24), and sigmoidectomies (OR 1.51, 95%CI 1.39-1.65, relative to right hemicolectomies) were the strongest predictors of "late" readmission. On multiple linear regression, "late" readmissions were associated with a $1717.09 USD (95%CI $1717.05-$1717.12) increased cost compared to "early" readmissions., Discussion: The majority of colectomy-related readmissions following emergency colectomy occur beyond POD30 and are associated with cases that are of overall higher morbidity, as well as open sigmoidectomies. Given the associated increased cost of care, mitigation of such readmissions by close follow-up prior to and beyond POD30 is advisable., (© 2024. The Author(s).)

Purpose: Recent studies have suggested that extended mesenteric excision (ME) may reduce surgical reintervention in Crohn's Disease (CD), but there remains clinical concerns regarding potential peri-operative morbidity. This retrospective study compares 30-day perioperative morbidity between limited and extended ME in segmental colectomies for CD., Methods: Using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) colectomy-specific database, all patients with CD undergoing segmental colectomy for non-malignant indications between 2014-2019 were included. A lymph node harvest of 12 or more nodes was used as a surrogate for extended ME. The primary outcome was NSQIP major morbidity. Secondary outcomes included abdominal complications and perioperative bleeding., Results: Of 3,709 patients included from the ACS-NSQIP database, 3,087 underwent limited ME and 622 underwent extended ME. On univariate analysis, those with limited mesenteric excision were less likely to be anemic (46.1% vs 55.0%, p < 0.001) and have undergone an open surgery (44.7% vs 34.7%, p < 0.001). On univariate comparison of limited and extended ME, there was no significant difference in major morbidity. On multiple logistic regression, controlling for age, sex, BMI, smoking, preoperative sepsis, preoperative anemia, surgical approach, emergency surgery, stoma creation, bowel preparation, and immunosuppression, the extent of ME was not an independent predictor of NSQIP major morbidity (OR 1.1, 95% CI 0.84-1.44). Likewise, the extent of ME was not associated with an increase in abdominal complications (OR 0.95, 95% CI 0.76-1.19) or post-operative bleeding (OR 1.89, 95% CI 0.75-1.53)., Conclusion: Extended ME for CD was not associated with an increase in 30-day perioperative major morbidity., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Low anterior resection syndrome (LARS) is a well-described consequence of rectal cancer treatment. Studying the degree to which bowel dysfunction exists in the general population may help to better interpret to what extent LARS is related to disease and/or cancer treatment. Currently, North American LARS normative data are lacking. The aim of this study was to describe the prevalence of bowel dysfunction, as measured by the LARS score, and quality of life (QoL) in a reference North American sample. Quality of life was measured and associations between participant characteristics and LARS were identified., Study Design: This was a single-institution cross-sectional study of asymptomatic adults who underwent screening and surveillance colonoscopies from 2018 to 2021 with no/benign endoscopic findings. Survey was conducted on select comorbidities, sociodemographic factors, LARS, and QoL. Outcomes were LARS and QoL. Multivariable linear regression accounting for a priori clinical factors associated with bowel dysfunction was performed., Results: Of 1,004 subjects approached, 502 (50.0%) participated, and 135 (26.9%) participants had major/minor LARS. On multiple linear regression, female sex (β = 2.15, 95% CI 0.30 to 4.00), younger age (β = -0.10, 95% CI -0.18 to -0.03), White ethnicity (β = 2.45, 95% CI 0.15 to 4.74), and the presence of at least one of the following factors: diabetes, depression, neurologic disorder, or cholecystectomy (β = 3.54, 95% CI 1.57 to 5.51) were independently associated with a higher LARS score. Individuals with LARS had lower global QoL, functional subscales, and various symptom subscale scores., Conclusions: Our study identified the baseline prevalence of LARS in asymptomatic adults who have not undergone a low anterior resection. These normative data will allow for more accurate interpretation of ongoing studies on LARS in North American rectal cancer patients., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Historically, Hartmann's procedure (HP) has been the operation of choice for diverticulitis in the emergency setting. However, recent evidence has demonstrated the safety of primary anastomosis (PA) with or without diverting ileostomy. The purpose of this study was to evaluate the trends of, and factors associated with, HP compared to PA in emergency surgery for diverticulitis over 25 years., Methods: Using the National Inpatient Sample database, we identified adult patients ≥ 18 years old who underwent emergency surgery for diverticulitis (HP or PA) between 1993 and 2018 using ICD-9 and ICD-10 codes. Patients with inflammatory bowel disease, gastrointestinal cancer or who underwent elective diverticulitis surgery were excluded. Trends in HP were analyzed using multivariable linear regression, and factors associated with HP were assessed with multiple logistic regression., Results: Of 499,433 patients who underwent colectomy in the emergency setting for acute diverticulitis, 271,288 (54.3%) had a HP and 228,145 (45.7%) had a PA. Median age was 61 years (IQR: 50-73), 53% were women, and 70.5% were white. The proportion of HP slightly increased over the study period-HP comprised 52.6% of included cases in 1993-98 and 55.2% of cases in 2014-2018 (p = 0.017). Advanced age (reference = 18-44 years; 45-54 years: OR 1.16, 95% CI 1.10-1.22; 55-64 years: OR 1.26, 95% CI 1.20-1.33; 65-74 years: OR 1.33, 95% CI 1.25-1.42; ≥ 75 years: OR 1.51, 95% CI 1.41-1.62), complicated diverticulitis (OR 1.41, 95% CI 1.36-1.46), and severity of illness (reference = minor; moderate: OR 1.46, 95% CI 1.38-1.54; major/extreme: OR 3.43, 95% CI 3.25-3.63) were associated with increased odds of HP., Conclusions: Over a 26-year period, HP has remained the most performed procedure in the emergency setting for diverticulitis. Future work should focus on knowledge translation with a possible change in practice as more randomized controlled trials provide support for PA., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Most patients with rectal cancer experience bowel symptoms post-restorative proctectomy. The incidence of mental health disorders post-restorative proctectomy and its association with bowel symptoms are unknown., Objectives: This study aimed 1) to describe the incidence of mental health disorders in patients who underwent restorative proctectomy for rectal cancer and 2) to study the association between incident mental health disorders and bowel dysfunction after surgery., Design: This retrospective cohort study used the Clinical Practice Research Datalink and Hospital Episode Statistics databases., Settings: The databases were based in the United Kingdom., Patients: All adult patients who underwent restorative proctectomy for a rectal neoplasm between 1998 and 2018 were included., Main Outcome Measures: The primary outcome was an incident mental health disorder. The associations between bowel, sexual, and urinary dysfunctions and incident mental health disorders were studied using Cox proportional hazard regression models., Results: In total, 2197 patients who underwent restorative proctectomy were identified. Of 1858 patients without preoperative bowel, sexual, or urinary dysfunction, 1455 had no preoperative mental health disorders. In this cohort, 466 patients (32.0%) developed incident mental health disorders following restorative proctectomy during 6333 person-years of follow-up. On multivariate Cox regression, female sex (adjusted HR 1.30; 95% CI, 1.06-1.56), metastatic disease (adjusted HR 1.57; 95% CI, 1.14-2.15), incident bowel dysfunction (adjusted HR 1.41, 95% CI, 1.13-1.77), and urinary dysfunction (adjusted HR 1.57; 95% CI, 1.16-2.14) were found to be associated with developing incident mental health disorders post-restorative proctectomy., Limitations: This study was limited by its observational study design and residual confounding., Conclusions: Incident mental health disorders after restorative proctectomy for rectal cancer are common. The presence of bowel and urinary functional impairment significantly increases the risk of poor psychological outcomes among rectal cancer survivors., Con Los Trastornos De Salud Mental En Pacientes Con Cncer De Recto Posterior a Proctectoma Restauradora: ANTECEDENTES: La mayoría de los pacientes con cáncer de recto experimentan síntomas intestinales después de la proctectomía restauradora. Se desconoce la incidencia de trastornos de salud mental posteriores a la proctectomía restauradora y su asociación con síntomas intestinales.OBJETIVOS: Los objetivos de nuestro estudio son: a) describir la incidencia de trastornos de salud mental en pacientes sometidos a proctectomía restauradora por cáncer de recto; b) estudiar la asociación entre los trastornos de salud mental incidentes y la disfunción intestinal después de la cirugía.DISEÑO: Este fue un estudio de cohorte retrospectivo que utilizó las bases de datos Clinical Practice Research Datalink y Hospital Episode Statistics.ENTORNO CLÍNICO: Las bases de datos se basaron en el Reino Unido.PACIENTES: Se incluyeron todos los pacientes adultos que se sometieron a una proctectomía restauradora por una neoplasia rectal entre 1998 y 2018.PRINCIPALES MEDIDAS DE VALORACIÓN: El resultado primario fue un trastorno de salud mental incidente. Las asociaciones entre la disfunción intestinal, sexual y urinaria y los trastornos de salud mental incidentes se estudiaron utilizando modelos de regresión de riesgos proporcionales de Cox.RESULTADOS: En total, se identificaron 2.197 pacientes que se sometieron a proctectomía restauradora. De 1.858 pacientes sin disfunción intestinal, sexual o urinaria preoperatoria, 1.455 personas tampoco tenían trastornos de salud mental preoperatorios. En esta cohorte, 466 (32,0 %) pacientes desarrollaron trastornos de salud mental incidentes después de la PR durante 6333 años-persona de seguimiento. En la regresión multivariada de Cox, sexo femenino (HRa 1,30, IC 95% 1,06-1,56), enfermedad metastásica (HRa 1,57, IC 95% 1,14-2,15) e incidencia intestinal (HRa 1,41, IC del 95 %: 1,13 a 1,77) y la disfunción urinaria (aHR 1,57, IC del 95 %: 1,16 a 2,14) se asociaron con el desarrollo de trastornos de salud mental incidentes después de la proctectomía restauradora.LIMITACIONES: Este estudio estuvo limitado por el diseño del estudio observacional y la confusión residual.CONCLUSIÓN: Los trastornos de salud mental incidentes después de la proctectomía restauradora para el cáncer de recto son comunes. La presencia de deterioro funcional intestinal y urinario aumenta significativamente el riesgo de malos resultados psicológicos entre los sobrevivientes de cáncer de recto. (Traducción- Dr. Ingrid Melo )., (Copyright © The ASCRS 2023.)

Introduction: The objective of this study was to evaluate the impact of preoperative bowel stimulation on the development of postoperative ileus (POI) after loop ileostomy closure., Methods: This was a multicenter, randomized controlled trial (NCT025596350) including adult (≥ 18 years old) patients who underwent elective loop ileostomy closure at 7 participating hospitals. Participants were randomly assigned (1:1) using a centralized computer-generated sequence with block randomization to either preoperative bowel stimulation or no stimulation (control group). Bowel stimulation consisted of 10 outpatient sessions within the 3 weeks prior to ileostomy closure and was performed by trained Enterostomal Therapy nurses. The primary outcome was POI, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, on or after postoperative day 3, that either (a) required nasogastric tube insertion; or (b) was associated with two of the following: nausea/vomiting, abdominal distension, or the absence of flatus., Results: Between January 2017 and November 2020, 101 patients were randomized, and 5 patients never underwent ileostomy closure; thus, 96 patients (47 stimulated vs. 49 control) were analyzed according to a modified intention-to-treat protocol. Baseline characteristics were well balanced in both groups. The incidence of POI was lower among patients randomized to stimulation (6.4% vs. 24.5%, p = 0.034; unadjusted RR: 0.26, 95% CI 0.078-0.87). Stimulated patients also had earlier median time to first flatus (2.0 days (1.0-2.0) vs. 2.0 days (2.0-3.0), p = 0.025), were more likely to pass flatus on postoperative day 1 (46.8% vs. 22.4%, p = 0.022), and had a shorter median postoperative hospital stay (3.0 days (2.0-3.5) vs. 4.0 days (2.0-6.0), p = 0.003)., Conclusions: Preoperative bowel stimulation via the efferent limb of the ileostomy reduced POI after elective loop ileostomy closure., (© 2022. The Author(s).)

Background: Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC., Methods: A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively., Results: Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients., Conclusions: Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The use of Non-vitamin K antagonist oral anticoagulants (NOAC) has increased substantially since their introduction in 2010. The lack of readily available reversal agents poses a challenge in perioperative management. The aim of this study was to evaluate the impact of NOACs on the outcomes of emergency colectomies., Methods: All adult patients on long-term anticoagulation who underwent emergency colectomies were identified from the Nationwide Inpatient Sample (NIS) database from 2002 to 2018. Long-term anticoagulation was defined using ICD-9/10 codes. Two cohorts were compared: anticoagulated patients in the pre-NOAC era (2002-2010) and anticoagulated patients in the NOAC era (2010-2018). Outcomes of interest were postoperative surgical complications, mortality and need for transfusion., Results: Of 13,218 patients on long-term anticoagulation, 3,264 patients were treated in the pre-NOAC era and 9,954 in the NOAC era. Over the study period, there was a significant increase in the proportion of anticoagulated patients undergoing emergency colectomies (R 2  = 0.91). On univariate analysis, anticoagulated patients in the NOAC era were medically more comorbid and had higher rates of postoperative surgical complications (73.3% vs 60.3%, p < 0.001) and mortality (8.2% vs. 6.7%, p = 0.006), but had lower rates of postoperative bleeding (3.5% vs. 4.4%, p = 0.002) and transfusions (38.1% vs. 45.4%, p < 0.001). On multivariable regression, after accounting for clinically significant covariates, anticoagulation in the NOAC era was associated with decreased rates of postoperative bleeding (OR 0.70, 95%CI 0.57-0.88) and transfusions (OR 0.71 95%CI 0.64-0.77) but remained an independent predictor of increased overall postoperative complications (OR 1.26, 95%CI 1.14-1.39)., Conclusion: Prevalence of long-term anticoagulation in patients undergoing emergency colectomies is increasing. Although associated with lower rates of postoperative bleeding and transfusions, anticoagulation in the NOAC era is associated with higher rates of overall postoperative complications. Evidence-based guidelines for perioperative management of patients on NOACs in the emergency colorectal surgery setting are needed., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: The COVID-19 pandemic resulted in a partial to total shutdown of endoscopy in many healthcare centers. This study aims to quantify the impact of the reduction in colonoscopies on colorectal cancer (CRC) detection and screening., Methods: After institutional ethics board approval, the endoscopy database at an academic tertiary-care center in Montreal, Canada, was searched for all colonoscopies performed from during the first wave locally (March-June 2020), and during the ramp up period where endoscopy service resumed (July to August 2020). We compared these periods to the same periods in 2019, the pre-pandemic periods. The indications, CRC and adenoma detection rates, as well as the prioritization of urgent procedures were compared., Results: In the first wave, only 462 colonoscopies were performed, compared to 2515 in the same period in 2019, an 82% reduction. The ramp up period saw 843 colonoscopies performed compared to 1328 in 2019, a 35% reduction. Urgent and inpatient colonoscopies numbers increased (324 (24.8%) vs. 220 (5.7%)) while surveillance and high-risk screening colonoscopies fell (376 (28.8%) vs 1869 (48.6%)). Emergency access to colonoscopy was preserved with a median time to endoscopy of < 1 day (IQR 0,1) in both pandemic periods. During the pandemic periods, there was an absolute reduction in CRC diagnosis of 28, despite the CRC detection per colonoscopy rate increasing slightly in the first wave from 1.7% (44) to 3.9% (18), and in the ramp up period from 2.5% (33) to 3.6% (31). The rate of adenoma detection per colonoscopy did not increase significantly between the pre- and pandemic periods, resulting in reduction in adenoma removal in 723 patients., Discussion: The restriction of access to colonoscopy resulted in a significant reduction in screening and surveillance of high-risk patients, adenomas removed, and CRCs diagnosed. Clinicians and patients will face the oncologic ramifications this the coming years., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Preoperative administration of oral antibiotic bowel preparation (OABP) alone has been shown to reduce infectious outcomes in patients undergoing elective colectomy. However, it remains unclear if these benefits extend to the emergency setting. This is a retrospective, propensity-score matched study comparing 30-day perioperative morbidity between those who received OABP alone versus no preparation prior to urgent colectomy., Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database, adults undergoing urgent colectomy from 2012 to 2019 were included. Those who were clinically obstructed or who received mechanical bowel preparation were excluded. Outcomes of interest included: surgical site infection (SSI), leak, ileus, and major morbidity., Results: Of 24,559 patients meeting inclusion criteria, 878 (3.6%) received OABP prior to urgent colectomy. Prior to matching, those receiving no preparation were more likely to have higher ASA class, diabetes, hypertension, preoperative sepsis, open procedures, and a dirty wound classification. After matching, 1756 patients, remained with 878 in each arm. Preoperative characteristics were balanced on univariate analysis. Postoperatively, patients receiving OABP experienced decreased organ space SSI (11.2% vs. 15.5%, p = 0.009) and ileus (30.3% vs. 35.3%, p = 0.029), with no difference in leak rates (3.3% vs 3.3%, p = 1.000) or NSQIP major morbidity (47.4% vs. 49.9%, p = 0.316). On multivariate logistic regression, including propensity score, the reduction in organ space SSI associated with OABP persisted (OR 0.684, 95% CI 0.516-0.903)., Conclusion: OABP prior to select urgent colectomies was associated with fewer organ space SSIs and may be considered when feasible., (© 2022. The Society for Surgery of the Alimentary Tract.)

Background: Implementation of early discharge in colorectal surgery has been effective in improving patient satisfaction and reducing healthcare costs. Readmission rates following early discharge among colorectal cancer patients are believed to be low, however, remain understudied. The objectives of this study were: (i) to describe trends in early post-operative discharge and the associated hospitalization costs; (ii) to explore patient outcomes and resource utilization following early discharge; and (ii) to identify predictors of readmission following early discharge., Methods: This was a retrospective cohort study using the Nationwide Readmissions Database. Adult patients admitted with a primary colorectal neoplasm who underwent colectomy or proctectomy between 2010 and 2017 were identified using ICD-9/10 codes. The exposure of interest was early post-operative discharge defined as ≤ 3 days from surgery. Main outcome measures were 30-day readmissions, post-operative complication rates, LOS and cost., Results: In total, 342,242 patients were identified, and of those, 51,977 patients (15.2%) had early discharges. During the study period, the proportion of early discharges significantly increased (R 2  = 0.94), from 9.9 to 23.4%, while readmission rates in this group remained unchanged (mean 7.3% ± 0.5). Complications that required bounceback readmission (within 7 days) after early discharge, rather than during index admission, were an independent predictor of longer overall LOS (ß = 0.044, p < 0.001) and higher hospitalization costs (ß = 0.031, p < 0.001). On multiple logistic regression, factors independently associated with bounceback readmission following early discharge were: male gender (OR = 1.47, 95%CI 1.33-1.63); open surgery (OR = 1.37, 95%CI 1.23-1.52); presence of stoma (OR = 1.51, 95%CI 1.22-1.87); transfer to facility or discharge with home health service (OR = 1.53, 95%CI 1.34-1.75); and Medicare/Medicaid insurance (OR = 1.34, 95%CI 1.14-1.57), among others., Conclusion: Early post-operative discharge of colorectal cancer patients is increasing despite a lack of improvement in readmission rates and an overall increase in hospitalization costs. Premature discharge of select patients may result in readmissions due to critical complications related to surgery resulting in increased resource utilization., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The purpose of this study was to describe postoperative bowel dysfunction after restorative proctectomy, and to identify factors associated with its development., Methods: Patients who underwent restorative proctectomy for rectal cancer between April 1998 and November 2018 were identified from the Hospital Episode Statistics database and linked to the Clinical Practice Research Datalink for postoperative follow-up. Bowel dysfunction was defined according to relevant symptom-based read codes and medication prescription-product codes. A Cox proportional hazards model was performed to identify factors associated with postoperative bowel dysfunction, adjusting for relevant covariates., Results: In total, 2,197 patients were included. The median age was 70.0 (interquartile range: 62.0-77.0) years old, and the majority (59.2%) of patients were male. After a median follow-up of 51.6 (24.0-90.0) months, bowel dysfunction was identified in 620 (28.2%) patients. Risk factors for postoperative bowel dysfunction included extremes of age (<40 years old: adjusted hazards ratio 2.35, 95% confidence interval 1.18-4.65; 70-79 years old: adjusted hazards ratio 1.25, 95% confidence interval 1.03-1.52), radiotherapy (adjusted hazards ratio 1.94, 95% confidence interval 1.56-2.42), distal tumors (adjusted hazards ratio 1.62, 95% confidence interval 1.34-1.94), history of diverting ostomy (adjusted hazards ratio 1.58, 95% confidence interval 1.33-1.89), and anastomotic leak (adjusted hazards ratio 1.48, 95% confidence interval 1.06-2.05). A minimally invasive surgical approach was protective for postoperative bowel dysfunction (adjusted hazards ratio 0.68, 95% confidence interval 0.53-0.86)., Conclusion: Bowel dysfunction was common after restorative proctectomy, and several patient, disease, and treatment-level factors were associated with its development., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Fewer than 10% of colon cancers are found at the splenic flexure. A standard surgical approach to these cancers has not been defined. The goal of this study was to compare lymph node harvest and post-operative morbidity between segmental resection and formal left hemicolectomy for splenic flexure colon cancers., Method: Patients diagnosed with a splenic flexure cancer were identified from the 2012-2018 ACS-NSQIP colectomy-targeted database. Patients were categorized based on type of surgical resection - left hemicolectomy with colorectal anastomosis or segmental colectomy with colocolonic anastomosis. Demographic, clinicopathologic, and post-operative outcomes were compared between groups. Factors independently associated with lymph node harvest, operative time, and post-operative morbidity were investigated by linear and binomial logistic regression models., Results: A total of 3,049 patients underwent colectomy for a splenic flexure cancer. Of these, 83.6% had a segmental colectomy and 73% were performed by a minimally invasive approach. T- and N-stage did not differ between segmental and left hemicolectomy groups (p = 0.703 and p = 0.429, respectively). Inadequate nodal harvest (< 12 nodes) was infrequent and similar between the two procedures (7.4% vs. 9.1%, p = 0.13). Operative time was significantly shorter for segmental colectomy (213 ± 83.5 min vs. 193 ± 84.1 min, p < 0.0001) and major morbidity was similar between the two surgical techniques (8.4% vs. 8.9%, p = 0.75). After accounting for demographic, clinicopathologic, and operative factors, binomial logistic regression showed that type of procedure was not significantly associated with LN harvest (OR 0.80, 95%CI 0.54-1.17) or major morbidity (OR 1.17, 95%CI 0.36-3.81). However, on linear regression, segmental splenic flexure resection was associated with shorter operative time (estimate 20.29, 95%CI 12.61-27.97, p < 0.0001)., Conclusion: Splenic flexure resection for colon cancer is associated with an adequate lymph node harvest. Compared to a formal left hemicolectomy, a segmental resection also has a shorter operative time with equivalent post-operative morbidity., (© 2021. Crown.)

Background: We explored image-guided adaptive endorectal brachytherapy patients electing non-operative management for rectal cancer. We present the first pre-planned interim analysis., Methods: In this open-label phase II-III randomized study, patients with operable cT2-3ab N0 M0 rectal cancer received 45 Gy in 25 fractions of pelvic external beam radiotherapy (EBRT) with 5-FU/Capecitabine. They were randomized 1:1 to receive either an EBRT boost of 9 Gy in 5 fractions (Arm A) or three weekly adaptive brachytherapy (IGAEBT) boosts totaling 30 Gy (Arm B). Patient characteristics and toxicity are presented using descriptive analyses; TME-free survival between arms with the intention to treat the population is explored using the Kaplan-Meier method., Results: A total of 40 patients were in this analysis. Baseline characteristics were balanced; acute toxicities were similar. Complete clinical response (cCR) was 50% ( n = 10/20) in Arm A and 90% in Arm B ( n = 18/20). Median follow-up was 1.3 years; 2-year TME-free survival was 38.6% (95% CI: 16.5-60.6%) in the EBRT arm and 76.6% (95% CI: 56.1-97.1%) in the IGAEBT arm., Conclusions: Radiation intensification with IGAEBT is feasible. This interim analysis suggests an improvement in TME-free survival when comparing IGAEBT with EBRT, pending confirmation upon completion of this trial.

Background: Colorectal cancer is increasing in young adults. Our understanding of the adenoma-carcinoma sequence in young patients aged <50 years is lacking. The yield obtained by lowering the age of screening colonoscopy remains unclear., Objective: The goal of this study was to understand the burden and histology of colorectal polyps in young adults and to explore predictors of adenoma detection in this population., Design: This is a retrospective cohort study., Setting: Colonoscopies were performed at a single university-affiliated tertiary care center., Patients: This study included adults aged <50 years who underwent a colonoscopy between 2014 and 2019. Patients with inflammatory bowel disease and genetic disorders were excluded., Main Outcome Measures: Adenoma detection rates were analyzed according to age. Predictors of adenoma detection were investigated by multiple logistic regression., Results: A total of 4475 patients were analyzed. The mean age was 40.2 ± 8.0 years, 56.4% were female, and the mean BMI was 26.3 ± 5.5 kg/m2. A family history of colorectal cancer was reported in 23.8% of patients. The overall polyp and adenoma detection rates were 22% and 14%. The majority of polyps were adenomatous (58.9% of all polypectomies) and located in the left colon or rectum (61.4%). The detection rates of adenomas, advanced neoplasias, and adenocarcinomas were highest in patients aged 45 to 49 (19.3%, 4.8%, and 1.3%). On multivariate analysis, variables independently associated with adenoma detection included age (OR 1.08, 95% CI, 1.06-1.1), female sex (OR 1.80, 95% CI, 1.44-2.27), BMI (OR 1.01, 95% CI, 1.01-1.05), and having undergone a diagnostic colonoscopy (OR 1.81, 95% CI, 1.44-2.29). On subgroup analysis of patients aged 45 to 49, the same variables remained associated with adenoma detection except for age., Limitations: The study was limited due to the retrospective nature with heterogenous data., Conclusions: Adenoma detection in young adults aged 45 to 49 approaches the current adenoma detection of older adults. Predictors of adenoma detection in these young adults are female gender and BMI, which may help guide colorectal cancer screening guidelines in the future. See Video Abstract at http://links.lww.com/DCR/B843., Comprender De La Carga De Los Adenomas Colorrectales En Pacientes Aos Un Estudio De Cohorte Retrospectivo De Un Solo Centro: ANTECEDENTES:El cáncer colorrectal está aumentando en adultos jóvenes. No se conoce la secuencia adenoma-carcinoma en pacientes jóvenes <50 años. El rendimiento obtenido al reducir la edad de la colonoscopia de detección sigue sin estar claro.OBJETIVO:Comprender la carga y la histología de los pólipos colorrectales en adultos jóvenes y explorar los predictores de detección de adenomas en esta población.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Las colonoscopias se realizaron en un único centro de atención terciario afiliado a la universidad.PACIENTES:Adultos jóvenes <50 años que se sometieron a una colonoscopia entre 2014-2019. Se excluyeron los pacientes con enfermedad inflamatoria intestinal y trastornos genéticos.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron las tasas de detección de adenomas según la edad. Los predictores de la detección de adenomas se investigaron mediante regresión logística múltiple.RESULTADOS:Se analizaron 4475 pacientes. La edad media fue de 40,2 ± 8,0 años, el 56,4% eran mujeres y el IMC medio fue de 26,3 ± 5,5 kg / m2. Se informó de antecedentes familiares de cáncer colorrectal en el 23,8% de los pacientes. Las tasas generales de detección de pólipos y adenomas fueron del 22% y el 14%, respectivamente. La mayoría de los pólipos eran adenomatosos (58,9% de todas las polipectomías) y estaban localizados en colon izquierdo o recto (61,4%). Las tasas de detección de adenomas, neoplasias avanzadas y adenocarcinomas fueron más altas en pacientes de 45 a 49 años (19,3%, 4,8% y 1,3%, respectivamente). En el análisis multivariado, las variables asociadas de forma independiente con la detección de adenomas incluyeron: edad (OR 1.08; IC del 95%: 1,06-1,1), sexo femenino (OR 1,80; IC del 95%: 1,44-2,27), IMC (OR 1,01; IC del 95%: 1,01-1,05)) y haber sido sometido a una colonoscopia diagnóstica (OR 1,81; IC 95% 1,44-2,29). En el análisis de subgrupos de pacientes de 45 a 49 años, las mismas variables permanecieron asociadas con la detección de adenomas, excepto la edad.LIMITACIONES:Carácter retrospectivo con datos heterogéneos.CONCLUSIONES:La detección de adenomas en adultos jóvenes de 45 a 49 años se acerca a la detección actual de adenomas en adultos mayores. Los predictores de la detección de adenomas en estos adultos jóvenes son el sexo femenino y el IMC, que pueden ayudar a guiar las pautas de detección del cáncer colorrectal en el futuro. Consulte Video Resumen en http://links.lww.com/DCR/B843. (Traducción-Dr. Hagerman)., Competing Interests: Financial Disclosures: No conflicts of interest., (Copyright © The ASCRS 2022.)

Background: The purpose of this study was to determine if observational therapy is noninferior to antibiotics for acute uncomplicated diverticulitis according to clinically relevant margins., Methods: MEDLINE, EMBASE, and Cochrane were systematically searched by 2 independent reviewers to identify comparative studies of observational therapy versus antibiotics for acute uncomplicated diverticulitis. Non-inferiority margins (ΔNI) for each outcome were based on Delphi consensus including 50 patients and 55 physicians: persistent diverticulitis (ΔNI = 4.0%), progression to complicated diverticulitis (ΔNI = 3.0%), and time to recovery (ΔNI = 5 days). Risk differences and mean differences were pooled using random-effects meta-analysis. One-sided 90% confidence intervals and Z-tests were used to determine non-inferiority. A sensitivity analysis was performed, excluding patients post hoc determined to have complicated diverticulitis., Results: Nine studies (3 randomized controlled trials, 6 observational studies) met inclusion criteria: observational therapy (n = 2,011) versus antibiotics (n = 1,144). Observational therapy was noninferior to antibiotics regarding the risk of persistent diverticulitis (pooled risk differences: -0.39%, 90% CI -3.22 to 2.44%, ΔNI: 4.0%, P NI < 0.001; I 2  = 66%) and progression to complicated diverticulitis (pooled risk differences: -0.030%, 90% CI -0.99 to 0.92%, ΔNI: 3.0%, P NI < 0.001; I 2  = 0%). On sensitivity analysis, observational therapy remained noninferior for both outcomes. When stratified by study design, observational therapy also remained noninferior for both outcomes among randomized controlled trials only. Only 1 study reported on time to recovery as a continuous outcome, with no statistical difference between antibiotics and observational therapy., Conclusion: According to clinically relevant ΔNIs, observational therapy was noninferior to antibiotics for the treatment of acute uncomplicated diverticulitis with regard to persistent diverticulitis and progression to complicated diverticulitis., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Persistent (or ongoing) diverticulitis is a well-recognized outcome after treatment for acute sigmoid diverticulitis; however, its definition, incidence, and risk factors, as well as its long-term implications, remain poorly described., Objective: The purpose of this study was to assess the incidence, risk factors, and long-term outcomes of persistent diverticulitis., Design: This was a retrospective cohort study., Settings: Two university-affiliated hospitals in Montreal, Quebec, Canada were included., Patients: The study was composed of consecutive patients managed nonoperatively for acute sigmoid diverticulitis., Intervention: Nonoperative management of acute sigmoid diverticulitis was involved., Main Outcome Measures: Persistent diverticulitis, defined as inpatient or outpatient treatment for signs and symptoms of ongoing diverticulitis within the first 60 days after treatment of the index episode, was measured., Results: In total, 915 patients were discharged after an index episode of diverticulitis managed nonoperatively. Seventy-five patients (8.2%; 95% CI, 6.5%-10.2%) presented within 60 days with persistent diverticulitis. Factors associated with persistent diverticulitis were younger age (adjusted OR = 0.98 (95% CI, 0.96-0.99)), immunosuppression (adjusted OR = 2.02 (95% CI, 1.04-3.88)), and abscess (adjusted OR = 2.05 (95% CI, 1.03-3.92)). Among the 75 patients with persistent disease, 42 (56.0%) required hospital admission, 6 (8.0%) required percutaneous drainage, and 5 (6.7%) required resection. After a median follow-up of 39.0 months (range, 17.0-67.3 mo), the overall recurrence rate in the entire cohort was 31.3% (286/910). After excluding patients who were managed operatively for their persistent episode of diverticulitis, the cumulative incidence of recurrent diverticulitis (log-rank: p < 0.001) and sigmoid colectomy (log-rank: p < 0.001) were higher among patients who experienced persistent diverticulitis after the index episode. After adjustment for relevant patient and disease factors, persistent diverticulitis was associated with higher hazards of recurrence (adjusted HR = 1.94 (95% CI, 1.37-2.76) and colectomy (adjusted HR = 5.11 (95% CI, 2.96-8.83))., Limitations: The study was limited by its observational study design and modest sample size., Conclusions: Approximately 10% of patients experience persistent diverticulitis after treatment for an index episode of diverticulitis. Persistent diverticulitis is a poor prognostic factor for long-term outcomes, including recurrent diverticulitis and colectomy. See Video Abstract at http://links.lww.com/DCR/B593., Repercusiones a Largo Plazo De La Diverticulitis Persistente Estudio De Una Cohorte Retrospectiva De Pacientes: ANTECEDENTES:La diverticulitis persistente (o continua) es un resultado bien conocido posterior al tratamiento de la diverticulitis aguda del sigmoides; sin embargo, la definición, incidencia y factores de riesgo, así como sus repercusiones a largo plazo siguen estando descritas de manera deficiente.OBJETIVO:Evaluar la incidencia, los factores de riesgo y los resultados a largo plazo de la diverticulitis persistente.DISEÑO:Estudio de una cohorte retrospectiva.AMBITO:Dos hospitales universitarios afiliados en Montreal, Quebec, Canadá.PACIENTES:pacientes consecutivos tratados sin cirugia por diverticulitis aguda del sigmoides.INTERVENCIÓN:Tratamiento no quirúrgico de la diverticulitis aguda del sigmoides.PRINCIPALES RESULTADOS EVALUADOS:Diverticulitis persistente, definida como tratamiento hospitalario o ambulatorio por signos y síntomas de diverticulitis continua dentro de los primeros 60 días posteriores al tratamiento del episodio índice.RESULTADOS:Un total de 915 pacientes fueron dados de alta posterior al episodio índice de diverticulitis tratados sin cirugia. Setenta y cinco pacientes (8,2%; IC del 95%: 6,5-10,2%) presentaron diverticulitis persistente dentro de los 60 días. Los factores asociados con la diverticulitis persistente fueron una edad menor (aOR: 0,98, IC del 95%: 0,96-0,99), inmunosupresión (aOR: 2,02, IC del 95%: 1,04-3,88) y abscesos (aOR: 2,05, IC del 95%: 1,03-3,92). Entre los 75 pacientes con enfermedad persistente, 42 (56,0%) requirieron ingreso hospitalario, 6 (8,0%) drenaje percutáneo y 5 (6,7%) resección. Posterior a seguimiento medio de 39,0 (17,0-67,3) meses, la tasa global de recurrencia de toda la cohorte fue del 31,3% (286/910). Después de excluir a los pacientes que fueron tratados quirúrgicamente por su episodio persistente de diverticulitis, la incidencia acumulada de diverticulitis recurrente (rango logarítmico: p <0,001) y colectomía sigmoidea (rango logarítmico: p <0,001) fue mayor entre los pacientes que experimentaron diverticulitis persistente después el episodio índice. Posterior al ajuste de factores importantes de la enfermedad y del paciente, la diverticulitis persistente se asoció con mayores riesgos de recurrencia (aHR: 1,94, IC 95% 1,37-2,76) y colectomía (aHR: 5,11, IC 95% 2,96-8,83).LIMITACIONES:Diseño de estudio observacional, un modesto tamaño de muestra.CONCLUSIONES:Aproximadamente el 10% de los pacientes presentan diverticulitis persistente después del tratamiento del episodio índice de diverticulitis. La diverticulitis persistente, en sus resultados a largo plazo, es un factor de mal pronóstico, donse se inlcuye la diverticulitis recurente y colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B593., (Copyright © The ASCRS 2021.)

Aim: The aim of this study was to assess bowel-related financial stress and strain and to evaluate its association with global quality of life., Method: This was a retrospective cohort study with cross-sectional follow-up including consecutive patients who underwent restorative proctectomy for neoplastic disease of the rectum at a single university-affiliated hospital in Montreal, Quebec, Canada. Bowel-related financial impact and occupational impact were compared between patients with major low anterior resection syndrome (LARS) and those with minor/no LARS. The association between LARS, bowel-related financial impact and global quality of life (QoL) was then assessed in a multiple logistic regression model., Results: Of 180 eligible rectal cancer survivors who were contacted, 154 completed the questionnaires (response rate 47.1%) at a median follow-up of 57.5 months (interquartile range 34.1-98.1) after proctectomy. Individuals with major LARS reported a higher prevalence of bowel-related financial stress (53.2% vs 5.6%, p < 0.001) and strain (42.2% vs 5.6%, p < 0.001) compared with those with minor/no LARS. Among those who were working preoperatively (n = 100), the majority of participants with major LARS reported an impact of their new bowel function on their ability to work (70.6%), including delayed return to work (44.1%), the need to change schedules (35.3%) or roles (20.6%), and complete long-term medical absence from work (14.7%). On multiple logistic regression, major LARS with financial impact (OR 4.50, 95% CI 1.57-13.77) was associated with low global QoL compared with minor/no LARS., Conclusion: Major LARS was associated with considerable financial stress and strain and difficulties in returning to work., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Introduction: Diverting loop ileostomy (DLI) and colonic lavage has emerged as a valid alternative to total abdominal colectomy (TAC) for the surgical management of Clostridioides difficile colitis (CDC). However, little data are available on outcomes beyond the index admission. The objective of this study was to compare post-discharge outcomes between patients who underwent DLI and TAC for CDC., Methods: Adult patients who underwent DLI or TAC for CDC between 2011 and 2016 were identified from the Nationwide Readmissions Database, and only discharges between January and September in each calendar year were included to allow for a 90-day follow-up period for all cases. Ninety-day overall in-hospital mortality (index admission mortality plus 90-day post-discharge mortality) and 90-day unplanned readmissions were compared. To assess 6-month ileostomy reversal rates, the cohort was then truncated to exclude discharges after June in each calendar year. Multivariate regression was used to adjust for patient demographics and disease severity., Results: In total, 2070 patients were discharged between January and September of each included year: 1486 (71.8%) TAC compared to 584 (28.2%) DLI. Overall in-hospital mortality was higher among patients who underwent TAC (34.5% vs. 27.7%, p = 0.004); however, this association did not remain on multivariate regression (OR 1.14, 95% CI 0.91-1.43). Among the 1434 patients who were discharged alive, the 90-day unplanned readmission rate was similar in both groups (TAC: 26.1% vs. DLI: 23.1%, p = 0.26). After truncating the cohort to those patients discharged alive between January and June of each included year (n = 1016), patients who underwent DLI had a significantly greater 6-month ileostomy reversal rate (26.4% vs. 8.3%, p < 0.001). DLI was independently associated with higher odds of 6-month ileostomy reversal (OR 2.68, 95% CI 1.80-4.00)., Conclusions: In the surgical management of CDC, DLI is associated with equivalent mortality and unplanned readmission, but greater likelihood of 6-month ileostomy reversal, compared to TAC.

Aim: Low anterior resection syndrome (LARS) refers to a constellation of bowel symptoms that affect the majority of patients following restorative proctectomy. LARS is associated with poorer quality of life (QoL), and can lead to distress, anxiety and isolation. Peer support could be an important resource for people living with LARS, helping them normalize and validate their experience. The aim of this work is to describe the development of an interactive online informational and peer support app for LARS and the protocol for a randomized controlled trial., Method: A multicentre, randomized, assessor-blind, parallel-groups pragmatic trial will involve patients from five large colorectal surgery practices across Canada. The trial will evaluate the impact of an interactive online informational and peer support app for LARS, consisting of LARS informational modules and a closed forum for peers and trained peer support mentors, on patient-reported outcomes of people living with LARS. The primary outcome will be global QoL at 6 months following app exposure. The treatment effect on global QoL will be modelled using generalized estimating equations. Secondary outcomes will include patient activation and bowel function as measured by LARS scores., Results: In order to better understand patients' interest and preferences for an online peer support intervention for LARS, we conducted a single institution cross-sectional survey study of rectal cancer survivors. In total, 35/69 (51%) participants reported interest in online peer support for LARS. Age <65 years (OR 9.1; 95% CI 2.3-50) and minor/major LARS (OR 20; 95% CI 4.2-100) were significant predictors of interest in LARS online peer support., Conclusion: There is significant interest in the use of online peer support for LARS among younger patients and those with significant bowel dysfunction. Based on results of the needs assessment study, the app content and features were modified reflect patients' needs and preferences. We are now in an optimal position to rigorously test the potential effects of this initiative on patient-centered outcomes using a randomized controlled trial., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Purpose: Adjuvant chemotherapy within 56 or 84 days following curative resection is globally accepted as the standard of care for stage III colon cancer as it has been associated with improved overall survival. Initiation of adjuvant chemotherapy within this time frame is therefore recommended by clinical practice guidelines, including the European Society for Medical Oncology. The objective of this study was to evaluate adherence to these clinical practice guidelines for patients with stage III colon cancer across the Rossy Cancer Network (RCN); a partnership of McGill University's Faculty of Medicine, McGill University Health Centre, Jewish General Hospital and St Mary's Hospital Center., Patients and Methods: 187 patients who had been diagnosed with stage III colon cancer and received adjuvant chemotherapy within the RCN partner hospitals from 2012 to 2015 were included. Patient and treatment information was retrospectively determined by chart review. Χ 2 and Wilcoxon rank-sum tests were used to measure associations and a multivariate Cox regression model was used to determine risk factors contributing to delays in administration of adjuvant chemotherapy., Results: The median turnaround time between surgery and adjuvant chemotherapy was 69 days. Importantly, only 27% of patients met the 56-day target, and 71% met the 84-day target. Increasing age, having more than one surgical complication and being diagnosed between 2013-2014 and 2014-2015 reduced the likelihood that patients met these targets. Furthermore, delays were observed at most intervals from surgery to first adjuvant chemotherapy treatment., Conclusion: Our study found that within these academic hospital settings, 27% of patients met the 56-day target, and 71% met the 84-day target. Delays were associated with hospital, surgeon and patient-related factors. Initiatives in quality improvement are needed in order to improve adherence to recommended treatment guidelines for prompt administration of adjuvant chemotherapy for stage III colon cancer., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Randomized studies have shown low compliance to adjuvant chemotherapy in rectal cancer patients receiving preoperative chemotherapy and external beam radiation (CT/EBRT) with total mesorectal excision. We hypothesize that giving neoadjuvant CT before local treatment would improve CT compliance., Methods: Between 2010-2017, 180 patients were randomized (2:1) to either Arm A (AA) with FOLFOX x6 cycles prior to high dose rate brachytherapy (HDRBT) and surgery plus adjuvant FOLFOX x6 cycles, or Arm B (AB), with neoadjuvant HDRBT with surgery and adjuvant FOLFOX x12 cycles. The primary endpoint was CT compliance to ≥85% of full-dose CT for the first six cycles. Secondary endpoints were ypT0N0, five-year disease free survival (DFS), local control and overall survival (OS)., Results: Patients were randomized to either AA (n = 120, median age (MA) 62 years) or AB (n = 60, MA 63 years). 175/180 patients completed HDRBT as planned (97.2%). In AA, two patients expired during CT; three patients post-randomization received short course EBRT because of progression under CT (n = 2, AA) or personal preference (n = 1, AB). ypT0N0 was 31% in AA and 28% in AB (p = 0.7). CT Compliance was 80% in AA and 53% in AB (p = 0.0002). Acute G3/G4 toxicity was 35.8% in AA and 27.6% in AB (p = 0.23). With a median follow-up of 48.5 months (IQR 33-72), the five-year DFS was 72.3% with AA and 68.3% with AB (p = 0.74), the five-year OS 83.8% for AA and 82.2% for AB (p = 0.53), and the five-year local recurrence was 6.3% for AA and 5.8% for AB (p = 0.71)., Conclusion: We confirmed improved compliance to neoadjuvant CT in this study. Although there is no statistical difference in ypT0N0 rate, local recurrence, and DFS between the two arms, a trend towards favourable oncological outcomes is observed., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Aim: Patients are not well informed about sexual dysfunction after rectal cancer surgery and often turn to the Internet for information. The purpose of this study was to assess online information for patients on sexual dysfunction after rectal cancer surgery., Methods: An online search of Google, Yahoo and Bing was performed using specific (e.g., rectal cancer surgery and vaginal pain) and general (e.g., rectal cancer surgery and sex) search terms. Inclusion criteria were websites in English, designed for patients, and including content regarding sexual dysfunction after rectal cancer surgery. Websites were assessed for readability (nine standardized tests), quality (DISCERN tool), suitability (Suitability Assessment of Materials tool), and content., Results: Of 5040 websites identified, 99 unique websites met inclusion criteria. Three (3%) websites fulfilled the American Medical Association recommendation of a 6th-grade reading level. Using the DISCERN instrument, two (2%) websites were assigned good/excellent quality, nineteen (19%) referenced their sources of information, and thirty-one (31%) fully discussed the impact of sexual dysfunction on quality of life. Using the SAM instrument, three (3%) websites were classified as highly suitable for rectal cancer patients, sixty-five (66%) were adequate, and thirty-one (31%) were inadequate. With regards to content, nine (9%) websites fully discussed the impact of sexual dysfunction on patients partners and fifty-one (52%) websites did not cover prognosis., Conclusion: Online health information available to patients on sexual dysfunction after rectal cancer surgery is suboptimal. Websites are not suitable, lack important content, and are written at too complex a reading level for patients., (© 2021 Association of Coloproctology of Great Britain and Ireland.)

Background: The purpose of this study was to develop and validate a prediction model and clinical risk score for Intensive Care Resource Utilization after colon cancer surgery., Methods: Adult (≥ 18 years old) patients from the 2012 to 2018 ACS-NSQIP colectomy-targeted database who underwent elective colon cancer surgery were identified. A prediction model for 30-day postoperative Intensive Care Resource Utilization was developed and transformed into a clinical risk score based on the regression coefficients. Model performance was assessed using the area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow goodness-of-fit test. The model was validated in a separate test set of similar patients., Results: In total, 54,893 patients underwent an elective colon cancer resection, of which 1224 (2.2%) required postoperative Intensive Care Resource Utilization. The final prediction model retained six variables: age (≥ 70; OR 1.90, 95% CI 1.68-2.14), sex (male; OR 1.73, 95% CI 1.54-1.95), American Society of Anesthesiologists score (III/IV; OR 2.52, 95% CI 2.15-2.95), cardiorespiratory disease (yes; OR 2.22, 95% CI 1.94-2.53), functional status (dependent; OR 2.81, 95% CI 2.22-3.56), and operative approach (open surgery; OR 1.70, 95% CI 1.51-1.93). The model demonstrated good discrimination (AUC = 0.73). A clinical risk score was developed, and the risk of requiring postoperative Intensive Care Resource Utilization ranged from 0.03 (0 points) to 19.0% (8 points). The model performed well on test set validation (AUC = 0.73)., Conclusion: A prediction model and clinical risk score for postoperative Intensive Care Resource Utilization after colon cancer surgery was developed and validated.

Introduction: The objective of this study was to determine whether right-sided colectomies (RC) were associated with a higher incidence of primary postoperative ileus (pPOI) compared to left-sided colectomies (LC)., Methods: Patients who underwent elective colectomy for neoplastic disease between 2012 and 2016 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. RC and LC were defined as having an ileocolic or colocolic/colorectal anastomosis, respectively. Coarsened Exact Matching (CEM) was used to balance the two groups (1:1) on important confounders. The association between type of colectomy and pPOI, defined as POI in the absence of intra-abdominal sepsis, was then assessed in a multiple logistic regression analysis of the matched data., Results: Of 40,636 patients who underwent a colectomy for neoplastic disease, 15,231 underwent a RC and 25,405 a LC. After CEM, 12,949 matched patients remained in each group, and all important confounders were well balanced. The incidence of pPOI was higher in the RC group (11.5% vs. 8.8%, p < 0.001). On multiple logistic regression, RC was associated with a 35% higher odds of developing pPOI compared to LC (OR 1.35, 95% CI 1.25-1.47). RC was also associated with increased risk for NSQIP-defined major morbidity (OR 1.10, 95% CI 1.01-1.20), 30-day readmission (OR 1.16, 95% CI 1.06-1.27), and increased length of stay (β = 0.16 days, 95% CI 0.11-0.22)., Conclusion: pPOI is more common after RC than LC. Future research should aim at better understanding the pathophysiology behind this increased risk and identifying interventions to mitigate pPOI in this population.

Background: The objective of this study was to describe conditional recurrence-free survival (RFS) of patients after an index episode of diverticulitis managed without surgery, and to estimate the difference in conditional RFS for diverticulitis according to specific risk factors., Methods: This was a multicentre retrospective cohort study including all patients managed without surgery for acute sigmoid diverticulitis at two university-affiliated hospitals in Montreal, Quebec, Canada. Conditional RFS for diverticulitis was estimated over 10 years of follow-up. A Cox proportional hazards model was performed at the index episode and again 2 years later., Results: In total, 991 patients were included for analysis. The 1, 2- and 3-year actuarial diverticulitis RFS rates were 81·1, 71·5 and 67·5 per cent respectively. Compared with the 1-year actuarial RFS rate of 81·1 per cent, the 1-year conditional RFS increased with each additional year survived recurrence-free, reaching 96·0 per cent after surviving the first 4 years recurrence-free. A similar phenomenon was observed for 2-year diverticulitis conditional RFS. Lower age (hazard ratio (HR) 0·98, 95 per cent c.i. 0·98 to 0·99), Charlson Co-morbidity Index score of 2 or above (HR 1·78, 1·32 to 2·39) and immunosuppression (HR 1·85, 1·38 to 2·48) were independently associated with recurrence of diverticulitis from the index episode. At 2 years from the index episode, immunosuppression was no longer associated with diverticulitis recurrence (HR 1·02, 0·50 to 2·09)., Conclusion: The conditional RFS of patients with diverticulitis improved with each year that was survived recurrence-free. Although several factors at index presentation may be associated with early recurrence, the conditional probability of recurrence according to many of these risk factors converged with time., (© 2020 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Background: Rates of colectomy for ulcerative colitis have been decreasing, particularly since the advent of biologics, but the subsequent impact of reduced colectomy rates on the development of neoplasms in chronically treated ulcerative colitis colons is unknown., Purpose: To determine trends in colectomy for colorectal neoplasms in adult patients with ulcerative colitis., Methods: Adult admissions with ulcerative colitis were identified from the National Inpatient Sample from 1993 to 2015. The rate of colectomy with concurrent colorectal neoplasm served as the primary outcome and was evaluated using time trend linear and multivariable regression., Results: There were 366,286 admissions with ulcerative colitis including 16,556 (4.5%) total colectomies. Of those undergoing colectomy, 2018 (12.2%) had a concurrent diagnosis of colorectal neoplasm. The proportion of colectomies for ulcerative colitis with concurrent colorectal neoplasm increased from 10.3 to 12.5% (p Trend = 0.004). Specifically, the proportion of colectomies performed for dysplasia/benign neoplasm and rectal cancer increased from 3.5 to 5.6% (p Trend < 0.001) and from 2.6 to 3.0% (p Trend = 0.028) respectively, and those for colon cancer remained stable (4.5 to 3.9%, p Trend = 0.423). On multivariate regression, year of colectomy was a significant predictor of colectomy for colorectal neoplasm (OR = 1.044, 95% CI = 1.025-1.062)., Discussion: Operative management of ulcerative colitis appears to be slowly increasing in oncological indications. The rising proportions of colectomies performed for colorectal neoplasms suggest the need for continued screening in these patients, including rectal surveillance.

Background: To date, the impact of family history on diverticulitis outcomes has been poorly described., Objective: This study aims to evaluate the association between family history and diverticulitis recurrence after an episode of diverticulitis managed nonoperatively., Design: This is a retrospective cohort study with prospective telephone follow-up., Settings: This study was conducted at 2 McGill University-affiliated tertiary care hospitals in Montreal, Canada., Patients: All immunocompetent patients with CT-proven left-sided diverticulitis who were managed nonoperatively from 2007 to 2017 were included., Intervention: A positive family history for diverticulitis, as assessed by a detailed telephone questionnaire, was obtained., Main Outcome Measures: The primary outcome was diverticulitis recurrence occurring >60 days after the index episode. Secondary outcomes included a complicated recurrence and >1 recurrence (ie, re-recurrence)., Results: Of the 879 patients identified in the database, 433 completed the telephone questionnaire (response rate: 48.9%). Among them, 173 (40.0%) had a positive family history of diverticulitis and 260 (60.0%) did not. Compared to patients with no family history, patients with family history had a younger median age (59.0 vs 62.0 years, p = 0.020) and a higher incidence of abscess (24.3% vs 3.5%, p < 0.001). After a median follow-up of 40.1 (17.4-65.3) months, patients with a positive family history had a higher cumulative incidence of recurrence (log-rank test: p < 0.001). On Cox regression, a positive family history remained associated with diverticulitis recurrence (HR, 3.74; 95% CI, 2.67-5.24). Among patients with a positive family history, >1 relative with a history of diverticulitis had a higher hazard of recurrence (HR, 2.93; 95% CI, 1.96-4.39) than patients with only 1 relative with a history of diverticulitis. Positive family history was also associated with the development of a complicated recurrence (HR, 8.30; 95% CI, 3.64-18.9) and >1 recurrence (HR, 2.03; 95% CI, 1.13-3.65)., Limitations: This study has the potential for recall and nonresponse bias., Conclusion: Patients with a positive family history of diverticulitis are at higher risk for recurrent diverticulitis and complicated recurrences. See Video Abstract at http://links.lww.com/DCR/B215. LOS ANTECEDENTES FAMILIARES ESTÁN ASOCIADOS CON DIVERTICULITIS RECURRENTE, DESPUÉS DE UN EPISODIO DE DIVERTICULITIS MANEJADA SIN OPERACIÓN: Hasta la fecha, el impacto de los antecedentes familiares en los resultados de la diverticulitis, ha sido mal descrito.Evaluar la asociación entre los antecedentes familiares y la recurrencia de diverticulitis después de un episodio de diverticulitis manejado de forma no operatoria.Estudio de cohorte retrospectivo con seguimiento telefónico prospectivo.Dos hospitales de atención terciaria afiliados a la Universidad McGill en Montreal, Canadá.Todos los pacientes inmunocompetentes con diverticulitis izquierda comprobada por TAC, que fueron manejados sin cirugía desde 2007-2017.Una historia familiar positiva para diverticulitis, según lo evaluado por un detallado cuestionario telefónico.El resultado primario fue la recurrencia de diverticulitis ocurriendo > 60 días después del episodio índice. Resultados secundarios incluyeron una recurrencia complicada y >1 recurrencia (es decir, re-recurrencia).De los 879 pacientes identificados en la base de datos, 433 completaron el cuestionario telefónico (tasa de respuesta: 48,9%). Entre ellos, 173 (40.0%) tenían antecedentes familiares positivos de diverticulitis y 260 (60.0%) no tenían. Comparados con los pacientes sin antecedentes familiares, los pacientes con antecedentes familiares tenían una mediana de edad más joven (59.0 vs 62.0 años, p = 0.020) y una mayor incidencia de abscesos (24.3% vs 3.5%, p < 0.001). Después de una mediana de seguimiento de 40.1 (17.4-65.3) meses, los pacientes con antecedentes familiares positivos tuvieron una mayor incidencia acumulada de recurrencia (prueba de log-rank: p < 0.001). En la regresión de Cox, un historial familiar positivo, permaneció asociado con recurrencia de diverticulitis (HR, 3.74; IC 95%, 2.67-5.24). Entre los pacientes con antecedentes familiares positivos, >1 familiar con antecedentes de diverticulitis, tuvieron mayores riesgos de recurrencia (HR, 2.93; IC 95%, 1.96-4.39) en comparación de los pacientes con solo 1 familiar. La historia familiar positiva también se asoció con el desarrollo de una recurrencia complicada (HR, 8.30; IC 95%, 3.64-18.9) y >1 recurrencia (HR, 2.03; IC 95%, 1.13-3.65).Potencial de recuerdo y sesgo de no respuesta.Los pacientes con antecedentes familiares positivos de diverticulitis tienen un mayor riesgo para diverticulitis recurrente y recurrencias complicadas. Consulte Video Resumen http://links.lww.com/DCR/B215. (Traducción-Dr. Fidel Ruiz Healy).

Background: Dehydration is the most common morbidity following creation of a diverting loop ileostomy (DLI). We aimed to develop and validate a prediction model and web-based risk calculator for readmission for dehydration following DLI creation., Methods: After institutional review board approval, we retrospectively reviewed the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database between 2012 and 2017. Adult patients (> 18 years) who underwent DLI with a resection for colorectal cancer, inflammatory bowel disease, or diverticulitis were identified. Patient demographics, operative and postoperative data were collected. The final prediction model, developed in 60% of the cohort (training set) and which modeled the 30-day cumulative incidence of readmission for dehydration, was selected using highest area under the receiver operating curve (AUC) criterion. Model calibration was assessed with the Hosmer-Lemeshow goodness-of-fit test. The model was then assessed in validation and test sets, using 20% of the cohort for each., Results: Of 25,638 patients in the ACS-NSQIP database who met inclusion criteria, 15,222 patients were randomly selected for the training set. The incidence of readmission for dehydration in this cohort was 2.1%. The final model with the highest AUC retained 12 candidate variables: age, sex, smoking status, diabetes, hypertension, American Society of Anesthesiologists score, type of admission, underlying diagnosis, procedure performed, operative time, index admission length of stay, and major morbidity. The model demonstrated good discrimination (AUC 0.76, 95% CI 0.74-0.79) and the Hosmer-Lemeshow goodness-of-fit test confirmed good calibration (p = 0.50). Five-thousand and seventy-three patients were available for the validation and test sets, respectively, and the model remained strong in both the validation and test sets (AUCs of 0.73 and 0.73, respectively). The prediction model was then converted into a web-based risk calculator., Conclusions: A prediction model and web-based risk calculator for readmission for dehydration after DLI creation was developed and validated, demonstrating good predictive capabilities.

Introduction: Low anterior resection syndrome (LARS) is described as disordered bowel function after rectal resection that leads to a detriment in quality of life, and affects the majority of individuals following restorative proctectomy for rectal cancer. The management of LARS includes personalised troubleshooting and effective self-management behaviours. Thus, affected individuals need to be well informed and appropriately engaged in their own LARS management. This manuscript describes the development of a LARS patient-centred programme (LPCP) and the study protocol for its evaluation in a randomised controlled trial., Methods and Analysis: This will be a multicentre, randomised, assessor-blind, parallel-groups, pragmatic trial evaluating the impact of an LPCP, consisting of an informational booklet, patient diaries and nurse support, on patient-reported outcomes after restorative proctectomy for rectal cancer. The informational booklet was developed by a multidisciplinary LARS team, and was vetted in a focus group and semistructured interviews involving patients, caregivers, and healthcare professionals. The primary outcome will be global quality of life (QoL), as measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30), at 6 months after surgery. The treatment effect on global QoL will be modelled using generalised estimating equations. Secondary outcomes include symptom change, patient activation, bowel function measures, emotional distress, knowledge about LARS and satisfaction with the LPCP., Ethics and Dissemination: The Research Ethics Committee (REC) at the Integrated Health and Social Services Network for West-Central Montreal (health network responsible for the Jewish General Hospital) is the overseeing REC for all Quebec sites. They have granted ethical approval (MP-05-2019-1628) for all Quebec hospitals (Jewish General Hospital, McGill University Health Center, CHU de Quebec) and have granted full authorisation to begin research at the Jewish General Hospital. Patient recruitment will not begin at the other Quebec sites until inter-institutional contracts are finalised and feasibility/authorisation for research is granted by their respective REC. The results of this study will be presented at national and international conferences, and a manuscript with results will be submitted for publication in a high-impact peer-reviewed journal., Trial Registration Number: NCT03828318; Pre-results., Competing Interests: Competing interests: ASL receives travel stipends from Merck and Servier, and is on the advisory committee of Novadaq. JFFJ received a research grant from Merck and fees for consulting from Shionogi., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The true incidence of, and risk factors for, readmission for treatment failure after nonoperative management of acute diverticulitis remain poorly understood., Objective: The purpose of this study was to describe the incidence and risk factors for readmission for treatment failure after nonoperative management of acute diverticulitis using a large national database., Design: This was a retrospective cohort study., Settings: A representative sample of admissions and discharges from hospitals in the United States captured in the National Readmissions Database were included., Patients: Adult patients (age ≥18 y) admitted with a primary diagnostic of colonic diverticulitis between 2010 and 2015 and who were managed nonoperatively and discharged from hospital alive were included., Interventions: Study intervention included nonoperative management, consisting of medical therapy with or without percutaneous drainage., Main Outcome Measures: Readmission for treatment failure (defined as a nonelective readmission for diverticulitis within 90 d of discharge), complicated treatment failure (defined as a treatment failure with complicated diverticulitis), and time-to-treatment failure were measured., Results: In total, 201,384 patients were included. The overall incidence of readmission for treatment failure was 6.6%. Treatment failure was significantly higher among patients with an index episode of acute complicated diverticulitis compared with acute uncomplicated diverticulitis (12.5% vs 5.7%; p < 0.001). The median time-to-readmission for treatment failure was 21.0 days (range, 20.4-21.6 d), and 85% of all readmissions occurred within 60 days of discharge. On multiple logistic regression, factors independently associated with readmission for treatment failure were an index admission of complicated diverticulitis (OR = 2.06 (95% CI, 1.97-2.16)), disposition on discharge (against medical advice: OR = 1.92 (95% CI, 1.66-2.20); home health care arrangements: OR = 1.24 (95% CI, 1.16-1.33)), and immunosuppression (OR = 1.42 (95% CI, 1.28-1.57)), among others. Risk factors for a complicated treatment failure were also described, after an index episode of complicated and uncomplicated diverticulitis., Limitations: The study was limited by residual confounding from missing covariates and its observational study design., Conclusions: The incidence of readmission for treatment failure after an episode of diverticulitis managed nonoperatively is 6.6%, and an index episode of complicated diverticulitis is the strongest risk factor for treatment failure. See Video Abstract at http://links.lww.com/DCR/B92. REINGRESO POR FRACASO DEL TRATAMIENTO DESPUÉS DEL TRATAMIENTO NO QUIRÚRGICO DE LA DIVERTICULITIS AGUDA: UN ANÁLISIS DE LA BASE DE DATOS DE REINGRESOS A NIVEL NACIONAL: La verdadera incidencia y los factores de riesgo para el reingreso por fracaso del tratamiento después de manejo no quirúrgico de la diverticulitis aguda siguen siendo mal definidos.Definir la incidencia y los factores de riesgo de reingreso por fracaso del tratamiento no quirúrgico de la diverticulitis aguda utilizando una base de datos nacional.Estudio de cohorte retrospectivo.Una muestra representativa de ingresos y egresos de hospitales en los Estados Unidos capturados en la base de datos nacional de reingresos hospitalarios.Pacientes adultos (≥18 años) ingresados con un diagnóstico primario de diverticulitis colónica entre 2010-2015, y que fueron tratados de forma no operativa y dados de alta del hospital vivos.Manejo no quirúrgico, que consiste en terapia médica con o sin drenaje percutáneo.Reingreso por fracaso del tratamiento (definido como un reingreso no electivo por diverticulitis dentro de los 90 días despues de ser dados de alta), fracaso del tratamiento complicado (definido como un fracaso del tratamiento con diverticulitis complicada) y el tiempo hasta el tratamiento en casos fracasaados.201.384 pacientes incluidos en total. La incidencia global de reingreso por fracaso del tratamiento fue del 6,6%. El fracaso del tratamiento fue significativamente mayor entre los pacientes con un episodio índice de diverticulitis aguda complicada en comparación con la diverticulitis aguda no complicada (12.5% vs. 5.7%, p <0.001). La mediana del tiempo hasta el reingreso por fracaso del tratamiento fue de 21.0 (20.4 - 21.6) días, y el 85% de todos los reingresos ocurrieron dentro de los 60 días posteriores a ser dados de alta. En la regresión logística múltiple, los factores asociados independientemente con el reingreso por fracaso del tratamiento fueron un índice de admisión de diverticulitis complicada (OR 2.06, IC 95% 1.97-2.16), disposición (de alta en contra del consejo médico: OR 1.92, IC 95% 1.66-2.2; atención médica domiciliaria: OR 1.24, IC 95% 1.16-1.33) e inmunosupresión (OR 1.42, IC 95% 1.28-1.57), entre otros. Los factores de riesgo para un fracaso del tratamiento complicado también se describieron, respectivamente, después de un episodio índice de diverticulitis complicada y no complicada.Covariables faltantes y diseño de estudio observacional.La incidencia de reingreso por fracaso del tratamiento después de un episodio de diverticulitis manejado de forma no operativa es del 6,6%, y un episodio índice de diverticulitis complicada es el factor de riesgo más fuerte para el fracaso del tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B92. (Traducción-Dr. Adrian E. Ortega).

Background: In 2016, the American Society of Colon and Rectal Surgeons published a rectal cancer surgery checklist composed of the essential elements of preoperative, intraoperative, and postoperative care for patients undergoing rectal cancer surgery., Objective: The purpose of this study was to assess whether compliance with preoperative checklist elements was associated with improved pathologic and 30-day postoperative outcomes after rectal cancer surgery., Design: This was a retrospective cohort study., Settings: The study involved North American hospitals contributing to the American College of Surgeons National Surgical Quality Improvement Program., Patients: Adult patients who underwent elective rectal cancer surgery from 2016 to 2017 were included., Intervention: The study encompassed checklist compliance with 6 preoperative elements from the checklist., Main Outcome Measures: Pathologic outcomes (circumferential resection margin status, distal resection margin status, and adequate lymph node harvest ≥12), 30-day surgical morbidity, and length of stay were measured., Results: In total, 2217 patients were included in the analysis. Individual compliance with the 6 available preoperative checklist items was variable, including 91.3% for pretreatment documentation of tumor location within the rectum, 86.8% for complete colonoscopy, 84.0% for appropriate preoperative stoma marking, 79.8% for appropriate use of neoadjuvant radiotherapy, 76.6% for locoregional staging, and 70.8% for distant staging. Only 836 patients (37.7%) had all 6 checklist elements complete, whereas 1381 (62.3%) did not. Compared with patients without checklist compliance, patients with checklist compliance were younger (60.0 vs 63.0 y; p < 0.001) but otherwise had similar demographic characteristics. On multivariate regression, checklist compliance was associated with lower odds of circumferential resection margin positivity (OR = 0.47 (95% CI, 0.31-0.71); p < 0.001), higher odds of an adequate lymph node harvest ≥12 (OR = 1.60 (95% CI, 1.29-2.00); p < 0.001), reduced surgical morbidity (OR = 0.78 (95% CI, 0.65-0.95); p = 0.01), and shorter length of stay (β = -0.87 (95% CI, -1.51 to -0.24); p = 0.007). The association between checklist compliance and reduced odds of circumferential resection margin positivity remained on sensitivity analysis (OR = 0.61 (95% CI, 0.42-0.88); p = 0.009) when adjusting for neoadjuvant radiation., Limitations: This study was limited by its absence of long-term oncologic data and missing variables., Conclusions: Compliance with 6 preoperative elements of the American Society of Colon and Rectal Surgeons rectal cancer surgery checklist was associated with significantly improved pathologic outcomes and reduced postoperative morbidity. See Video Abstract at http://links.lww.com/DCR/B80. EL CUMPLIMIENTO CON LOS ELEMENTOS PREOPERATORIOS DE LA LISTA DE VERIFICACIÓN DE CIRUGÍA PARA CÁNCER RECTAL DE LA SOCIEDAD AMERICANA DE CIRUJANOS DE COLON Y RECTO MEJORA LOS RESULTADOS HISTOPATOLÓGICOS Y POSTOPERATORIOS: En 2016, la Sociedad Americana de Cirujanos de Colon y Recto publicó una lista de verificación de cirugía de cáncer de recto que comprende los elementos esenciales de la atención pre, intra y postoperatoria para pacientes sometidos a cirugía de cáncer de recto.Evaluar si el cumplimiento con los elementos preoperatorios de la lista de verificación se asoció con mejores resultados histopatológicos y postoperatorios a 30 días después de la cirugía de cáncer rectal.Estudio de cohorte retrospectiva.Hospitales norteamericanos que contribuyen al Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos.Pacientes adultos que se sometieron a cirugía electiva de cáncer rectal entre 2016 y 2017.Cumplimiento de la lista de verificación con seis elementos preoperatorios de la lista de verificación.Resultados histopatológicos (estado del margen de resección circunferencial, estado del margen de resección distal, cosecha adecuada de ganglios linfáticos ≥12), morbilidad quirúrgica a 30 días y duración de la estadía.En total, 2,217 pacientes fueron incluidos en el análisis. El cumplimiento individual de los seis ítems disponibles de la lista de verificación preoperatoria fue variable: 91.3% para la documentación previa al tratamiento de la localización del tumor dentro del recto, 86.8% para colonoscopía completa, 84.0% para el marcado preoperatorio apropiado del sitio de estoma, 79.8% para el uso apropiado de radioterapia neoadyuvante, 76.6 % para estadificación locorregional y 70.8% para estadificación distante. Solo 836 (37.7%) pacientes tenían los seis elementos de la lista de verificación completos, mientras que 1,381 (62.3%) no. En comparación con los pacientes sin cumplimiento de la lista de verificación, los pacientes con cumplimiento de la lista de verificación eran más jóvenes (60.0 vs. 63.0 años, p <0.001), pero por lo demás tenían características demográficas similares. En la regresión multivariada, el cumplimiento de la lista de verificación se asoció con menores probabilidades de positividad en el margen de resección circunferencial (OR = 0.47; IC del 95%: 0.31-0.71, p <0.001), mayores probabilidades de una cosecha adecuada de ganglios linfáticos ≥12 (OR = 1.60, IC 95% 1.29-2.00, p <0.001), menor morbilidad quirúrgica (OR = 0.78, IC 95% 0.65-0.95, p = 0.01) y menor duración de estadía (β = -0.87, IC 95% -1.51 - - 0.24, p = 0.007). La asociación entre el cumplimiento de la lista de verificación y las probabilidades reducidas de positividad del margen de resección circunferencial se mantuvo en el análisis de sensibilidad (OR = 0.61; IC del 95%: 0.42-0.88, p = 0.009) al ser ajustado con radiación neoadyuvante.Ausencia de datos oncológicos a largo plazo y variables faltantes.El cumplimiento de seis elementos preoperatorios de la lista de verificación de cirugía de cáncer rectal de la Sociedad Americana de Cirujanos de Colon y Recto se asoció con resultados histopatológicos significativamente mejores y una menor morbilidad postoperatoria. Vea el resumen en video en http://links.lww.com/DCR/B80.

Purpose: Organ preservation or nonoperative management of rectal cancer is of growing interest. Image guided adaptive endorectal brachytherapy is a radiation dose escalation modality: we explored its role in elderly patients unfit for surgery and patients refusing surgery., Methods and Materials: In this registry study, patients with rectal cancer who were ineligible for surgery received 40 Gy in 16 fractions of pelvic external beam radiation therapy. They subsequently received 3 weekly image guided adaptive brachytherapy boosts of 10 Gy to the residual tumor, for a total of 30 Gy in 3 fractions. Complete clinical response (cCR) and local control were the primary endpoints., Results: 94 patients were included; the median age was 81.1 years. With a median follow-up of 1.9 years, the proportion of cCR was 86.2%, the tumor regrowth proportion was 13.6%, and the cumulative incidence of local relapse was 2.7% at 1 year and 16.8% at 2 years. When considering responders and nonresponders, the 2-year local control was 71.5%. The overall survival at 2 years was 63.6%. Acute rectal grade 1 to 2 toxicity included all patients: 12.8% of patients had late bleeding requiring iron replacement, blood transfusions, or argon plasma therapy., Conclusions: Results of this registry study, evaluating radiation dose escalation for elderly medically unfit patients with unselected tumors, reveal that a high proportion of patients achieved cCR with a manageable toxicity profile. This technology will likely contribute to the challenging nonoperative management paradigm of rectal cancer., (Copyright © 2019. Published by Elsevier Inc.)

Background: Clostridium difficile colitis is an increasingly important cause of morbidity and mortality. Fulminant C. difficile colitis (FCDC) is a severe form of the colitis driven by a significant systemic inflammatory response, and managed with a total abdominal colectomy. Despite surgery, postoperative mortality rates remain high. The aim of this study was to develop a bedside calculator to predict the risk of 30-day postoperative mortality for patients with FCDC., Methods: After institutional review board approval, the American College of Surgeons National Surgical Quality Improvement Program database (2005-2015) was used to include adult patients who underwent emergency surgery for FCDC. A priori preoperative predictors of mortality were selected from the literature: age, immunosuppression, preoperative shock, intubation, and laboratory values. The predictive accuracy of different logistic regression models was measured by calculating the area under the receiver-operating characteristic curve. A cohort of 124 patients from Québec was used to validate the developed mortality calculator., Results: A total of 557 patients met the inclusion criteria, and the overall mortality was 44%. After developing the calculator, no statistically significant differences were found in comparison with the American College of Surgeons National Surgical Quality Improvement Program probability of mortality available in the database (area under the receiver operating curve, 75.61 vs. 75.14; p = 0.79). External validation with the cohort of patients from Quebec showed an area under the curve of 74.0% (95% confidence interval, 65.0-82.9)., Conclusion: A clinically applicable calculator using preoperative variables to predict postoperative mortality for patients with FCDC was developed and externally validated. This calculator may help guide preoperative decision making., Level of Evidence: Prognostic and epidemiological study, level III.

Introduction: Postoperative ileus (POI) is regarded as the most clinically significant morbidity following loop ileostomy closure; however, its incidence remains poorly understood. Our objective was therefore to determine the pooled incidence of POI after loop ileostomy closure and identify risk factors associated with its development., Methods: We systematically searched MEDLINE (via Ovid and PubMed), Embase, the Cochrane Library, Biosis Previews, and Scopus to identify studies reporting the incidence of POI in patients who underwent loop ileostomy closure. Two independent reviewers extracted data and appraised study quality. Cumulative incidence proportions were pooled across studies using a random-effects meta-analytic model., Results: Sixty-seven studies, including 9528 patients, met our inclusion criteria. The pooled estimate of POI was 8.0% (95% CI 6.9-9.3%; I 2  = 74%). The estimated incidence varied by POI definition: studies with a robust definition of POI (n = 8) demonstrated the highest estimate of POI (12.4%, 95% CI 9.2-16.5%; I 2  = 79%) while studies that did not report an explicit POI definition (n = 38) demonstrated the lowest estimate (6.7%, 95% CI 5.3-8.3%; I 2  = 61%). Small bowel anastomosis technique (hand-sewn) and interval time from ileostomy creation to closure (longer time) were the factors most commonly associated with POI after loop ileostomy closure. However, most comparative studies were not powered to examine risk factors for POI., Conclusions: POI is an important complication after loop ileostomy closure, and its incidence is dependent on its definition. More research aimed at studying this complication is required to better understand risk factors for POI after loop ileostomy closure.

Background: The impact of immunosuppressants on postoperative complications following colon resections for Crohn's disease remains controversial. This study aimed to compare postoperative outcomes between immunosuppressed and immunocompetent patients with Crohn's disease undergoing elective colon resection., Methods: Analysis of 30-day outcomes using a cohort from the American College of Surgeons National Surgical Quality Improvement Program colectomy-specific database was performed. The database is populated by trained clinical reviewers who collect 30-day postoperative outcomes for patients treated at participating North-American institutions. Adult patients who underwent an elective colectomy between 2011 and 2015 were included. Immunosuppression for Crohn's disease was predefined as use of regular corticosteroids or immunosuppressants within 30 days of the operation. Patients who received chemotherapy within 90 days of surgery, and patients who had disseminated cancer, preoperative shock, or emergency surgery were excluded. Primary outcome was infectious complications., Results: Three thousand eight hundred sixty patients with Crohn's disease required elective colon resection and met the inclusion criteria. Of these, 2483 were immunosuppressed and 1377 were immunocompetent. On multivariate analysis, the odds of infectious complications [OR 1.25; 95% CI (1.033-1.523)], overall surgical site infection [1.40; (1.128-1.742)], organ space surgical site infection [1.47; (1.094-1.984)], and anastomotic leak [1.51; (1.018-2.250)] were significantly higher for immunosuppressed compared to immunocompetent patients with Crohn's disease., Conclusions: Patients with Crohn's disease who were on immunosuppressant medications within 30 days of elective colectomy had significantly increased rates of infectious complications, overall surgical site infection, organ space surgical site infection, and anastomotic leak compared to patients who were not on immunosuppressive agents.

Background: Endorectal brachytherapy is an attractive option in the neoadjuvant setting for locally advanced rectal cancer, but it is not considered standard of care., Objective: This study aimed to compare pathologic outcomes of patients with clinical T3 rectal cancer who underwent high-dose-rate endorectal brachytherapy with those who underwent conventional external beam radiotherapy., Design: This study is a retrospective chart review., Settings: This study was conducted in a single large tertiary academic colorectal surgery practice in Canada., Patients: Adult patients with MRI-staged T3 rectal adenocarcinoma treated with neoadjuvant radiotherapy followed by total mesorectal excision from 2007 to 2016 were included., Interventions: Neoadjuvant radiotherapy was delivered by high-dose-rate endorectal brachytherapy or conventional external beam radiotherapy., Main Outcome Measures: Primary outcome was pathologic complete response, defined as ypT0N0. Secondary outcomes included tumor (T stage) and lymph node (N stage) downstaging and tumor regression grade., Results: Ninety-nine patients were identified as having clinical T3 rectal cancer based on blinded pretreatment MRI review. Mean age was 66.2 years (± 6.2) and 59 patients (59.6%) were male. Thirty-three patients were clinically node negative (33.3%), 45 had c-N1 disease (45.5%), and 21 had c-N2 disease (21.2%). Sixty-four patients (64.6%) underwent high-dose-rate endorectal brachytherapy and 35 (35.4%) underwent external beam radiotherapy. The high-dose-rate endorectal brachytherapy group had a lower median mesorectal depth of invasion (4 mm vs 5 mm, p = 0.010); all other preoperative tumor characteristics were similar in both groups. Eighteen patients (18.2%) achieved pathologic complete response: 12 in the high-dose-rate endorectal brachytherapy group and 6 in the conventional external beam radiotherapy group (18.8% vs 17.1%, p = 0.84). High-dose-rate endorectal brachytherapy was superior to conventional radiotherapy for tumor (T stage) downstaging (59.4% vs 28.6%, p = 0.0030) but not for lymph node (N stage) downstaging (35.9% vs 51.4%, p = 0.14)., Limitations: This study was limited by its retrospective nature and modest sample size., Conclusions: Neoadjuvant treatment of T3 rectal cancer with high-dose-rate endorectal brachytherapy appears to achieve equivalent rates of pathologic complete response and superior T-stage downstaging compared with conventional external beam radiotherapy. See Video Abstract at http://links.lww.com/DCR/A905.

Background: There is ongoing debate regarding the benefits of minimally invasive techniques for rectal cancer surgery. The aim of this study was to compare pathologic outcomes of patients who underwent rectal cancer resection by open surgery, laparoscopy, and robotic surgery using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) proctectomy-targeted database., Methods: All patients from the 2016 ACS-NSQIP proctectomy-targeted database who underwent elective proctectomy for rectal cancer were identified. Patients were divided into three groups based on initial operative approach: open surgery, laparoscopy, and robotic surgery. Pathologic and 30-day clinical outcomes were then compared between the groups. A propensity score analysis was performed to control for confounders, and adjusted odds ratios for pathologic outcomes were reported., Results: A total of 578 patients were included-211 (36.5%) in the open group, 213 (36.9%) in the laparoscopic group, and 154 (26.6%) in the robotic group. Conversion to open surgery was more common among laparoscopic cases compared to robotic cases (15.0% vs. 6.5%, respectively; p = 0.011). Positive circumferential resection margin (CRM) was observed in 4.7%, 3.8%, and 5.2% (p = 0.79) of open, laparoscopic, and robotic resections, respectively. Propensity score adjusted odds ratios for positive CRM (open surgery as a reference group) were 0.70 (0.26-1.85, p = 0.47) for laparoscopy and 1.03 (0.39-2.70, p = 0.96) for robotic surgery., Conclusions: The use of minimally invasive surgical techniques for rectal cancer surgery does not appear to confer worse pathologic outcomes.

Background: This study aimed to define the incidence and risk factors of postoperative morbidity and mortality after pouch excision (PE)., Methods: ACS-NSQIP database was queried for patients who underwent PE between 2005 and 2015. Main outcome measures were 30-day mortality, major morbidity, overall surgical site infections (SSI), reoperation, and length of stay (LOS). Risk factors associated with these outcomes were assessed using multivariate logistic or quantile regression., Results: Three hundred eighty-one patients underwent PE (mean age 47.7(±15.3) years; 51.7% female). Mean body mass index (BMI) was 24.6(±5.7) kg/m 2 , 55.4% were ASA class 1-2 and 18.4% were immunosuppressed. Mean operative time was 252(±112.7) min, 98% were elective cases, and median LOS was 7(5-11) days. Twenty-eight percent experienced major morbidity, including SSIs (21.5% overall, 9.2% superficial, 3.7% deep, 10.3% organ space), sepsis (9.5%), urinary tract infection (5.8%), and postoperative pneumonia (2.4%). The observed venous thromboembolism rate was low, with 0.5 and 0.8% of patients suffering pulmonary embolism and deep vein thrombosis, respectively; 5.5% required reoperation. Postoperative mortality was 0.8%. On multivariate logistic regression, smoking (OR 3.03 [95% CI 1.56, 5.88]) and operative time (OR 1.003 [95% CI 1.0003, 1.0005) were associated with increased odds of major morbidity. Smoking (OR 3.29 [95% CI 1.65, 6.54]) and operative time (OR 1.002 [95% CI 1.000, 1.004]) were independent risk factors for overall SSI. LOS was significantly increased in patients with major morbidity (3.29 days [95% CI 1.60, 4.99]) and increased operative time (0.013 days [95% CI 0.007, 0.018])., Conclusions: PE is an operation with significant risk of morbidity. However, mortality was low in the present cohort of patients. Patients who were smokers and had longer operative time had increased risk of overall infectious complications and major morbidity. Furthermore, major morbidity and operative time were associated with increased hospital length of stay following PE.

This study queried American Society of Colon and Rectal Surgeons members for management of sigmoid volvulus and aimed to determine whether surgeon experience impacts decision-making. American Society of Colon and Rectal Surgeons members received a 16-item survey in March, 2017. Items included endoscopic detorsion technique and colonic decompression, preoperative dietary considerations, surgical approach, and respondents' demographics. Respondents were separated into low experience (LE; ≤10 years in practice) and high experience (HE; >10 years in practice). Of 1996 survey recipients, 10 per cent (197) responded; 124 were HE and 73 were LE. Most were fellowship-trained (93.8%) and primarily in colorectal surgery practice (74.6%), however only 27.4 per cent managed >20 sigmoid volvulus cases as attendings. Fifty-two per cent use rectal tubes for continued colonic decompression after successful endoscopic detorsion; 81.2 per cent would perform sigmoid colectomy on the index admission after successful detorsion, but within a variable timeframe (one to seven days postdetorsion) and with variable dietary restrictions in the interval period; 49.7 per cent would perform a laparoscopic colectomy and 68.3 per cent would perform a stapled colorectal anastomosis. LE surgeons reported a higher proportion of gastrointestinal-performed endoscopic detorsions ( P = 0.015), were more likely allow regular diet in the interval period ( P = 0.031), and were more inclined to use laparoscopy ( P = 0.008), versus HE surgeons. There remains controversy among many of the components in the management of sigmoid volvulus after successful endoscopic detorsion.

Background: The short-term benefits of laparoscopy for rectal surgery are equivocal. The objective of this study was to determine the clinical and economic impact of an enhanced recovery pathway (ERP) for laparoscopic and open rectal surgery., Materials and Methods: All patients who underwent elective rectal resection with primary anastomosis between January 2009 and March 2012 at two tertiary-care, university-affiliated institutions were identified. Patients who met inclusion criteria were divided into four groups, according to surgical approach (laparoscopic [lap] or open) and perioperative management (ERP or conventional care [CC]). Length of stay (LOS), postoperative complications, and hospital costs were compared., Results: A total of 381 patients were included in the analysis (201 open-CC, 34 lap-CC, 38 open-ERP, and 108 lap-ERP). Patients were mostly similar at baseline. ERPs significantly reduced median LOS after both open cases (open-CC 10 days versus open-ERP 7.5 days, P = .003) and laparoscopic cases (lap-CC 5 days versus lap-ERP 4.5 days, P = .046). ERPs also reduced variability in LOS compared with CC. There was no difference in postoperative complications with the use of ERPs (open-CC 51% versus open-ERP 50%, P = .419; lap-CC 32% versus lap-ERP 36%, P = .689). On multivariate analysis, both ERP (-3.6 days [95% confidence interval, CI -6.0 to -1.3]) and laparoscopy (-3.6 days [95% CI -5.9 to -1.0]) were independently associated with decreased LOS. Overall costs were only lower when lap-ERP was compared with open-CC (mean difference -2420 CAN$ [95% CI -5628 to -786])., Conclusions: ERPs reduced LOS after rectal resections, and the combination of laparoscopy and ERPs significantly reduced overall costs compared to when neither strategy was used.

Background: Clinical complete response (cCR) in rectal cancer is being evaluated as a tool to identify patients who would not require surgery in the curative management of rectal cancer. Our study reviews mucosal changes after neoadjuvant therapy for rectal cancer in patients treated at our center., Methods: Pathology reports were retrieved for patients treated with neoadjuvant chemoradiation therapy (CRT) or high-dose rate brachytherapy (HDRBT). The macroscopic appearance of the specimen was compared with pathologic staging., Results: This study included 282 patients: 88 patients underwent neoadjuvant CRT and 194 patients underwent HDRBT; all patients underwent total mesorectal excision (TME). There were 160 male and 122 female patients with a median age of 65 years (range 29-87). The median time between neoadjuvant therapy and surgery was 50 and 58 days. Sixty patients (21.2%) were staged as ypT0N0, 21.2% had a pathologic complete response (pCR), and only 3.2% had a cCR. Of the 67 patients with initial involvement of the circumferential radial margin (CRM), 44 converted to pathologic CRM-. Two hundred seventy-three patients (96.8%) had mucosal abnormalities. Of the 222 patients with residual tumor, 70 patients had no macroscopic tumor visualized but an ulcer in its place., Conclusion: Most patients undergoing neoadjuvant therapy for rectal cancer have residual mucosal abnormalities which preclude to a cCR as per published criteria from Brazil. Further studies are required to optimize clinical evaluation and MRI imaging in selected patients.

Background: We evaluated long-term incidence and identified risk factors of colectomy in pre-biologics and biologics eras for treatment of ulcerative colitis., Methods: After IRB approval, using data obtained from the Régie d'assurance maladie du Québec, we defined two cohorts: pre-biologics (1998-2004) and biologics (2005-2011) eras. Patients with inflammatory bowel disease or colectomy 1 year prior to first diagnosis of ulcerative colitis were excluded. Multivariate logistic regression model compared patient baseline characteristics. Kaplan-Meier curves displayed unadjusted time to event. Cox proportional hazards models were used to compare adjusted colectomy and mortality rates, respectively., Results: In pre-biologics and biologics eras, 335/2829 and 314/3313 patients, respectively, underwent colectomy. Median follow-up (first and third quartiles) was similar (p = 0.206). Incidence rates for colectomy were 36.08/1000 and 29.99/1000 patient years. Unadjusted rate of colectomy was higher in pre-biologics era (p = 0.004). Predictors of colectomy included anemia (1.66; 1.38-2.01), gastrointestinal hospitalizations (1.24; 1.04-1.47), congestive heart failure (2.08; 1.27-3.40), and male gender (1.47; 1.26-1.72). Mortality was 8.06 and 3.18% in pre-biologics and biologics eras. After adjusting for potential confounders, age (1.08; 1.05-1.12) and urgent colectomy (5.65; 2.19-14.54) remained associated with increased mortality hazard., Conclusion: Incidence of colectomy decreased after introduction of biologics. Risk factors for colectomy were gastrointestinal hospitalizations, anemia, male gender, and congestive heart failure. Emergent surgery and age were predictors of mortality.