Multiple High-Risk Features for Stage II Colon Carcinoma Portends Worse Survival Than Stage III Disease

BACKGROUND

High-risk features in stage II colon cancer worsen survival and serve as an impetus for adjuvant chemotherapy. Limited data exist on the effect of multiple high-risk features on survival.

OBJECTIVE

The study aimed to compare the survival of 0, 1, or multiple high-risk features in stage II to stage III colon cancer.

DESIGN

Patients with stage II and III colon cancer diagnosed between 2010 and 2016 were identified using the Survival, Epidemiology, and End Results database. Patients with stage II colon cancer were then classified according to the presence of 0, 1, or 2 or more of the following high-risk features: pathologic T4, perineural invasion, fewer than 12 lymph nodes assessed, or poor histologic differentiation. Overall survival and cause-specific survival were calculated. Each group was then stratified on the basis of whether chemotherapy was given.

SETTINGS

This study used the Survival, Epidemiology, and End Results database (2010-2016).

PATIENTS

Patients who had stage II or III colon cancer were included.

MAIN OUTCOME MEASURES

The primary outcome measures were 5-year overall survival and cause-specific survival.

RESULTS

A total of 65,831 patients were studied. Of these, 18,056 patients with stage II cancer had 0 high-risk features, 9426 had 1 high-risk feature, and 3503 had 2 or more high-risk features. There were 34,842 patients diagnosed with stage III disease. The 5-year overall survival and cause-specific survival for patients with stage II cancer with 2 or more high-risk features (49.2%, 59.5%) were lower than those without high-risk features (74.9%, 90.7%), with 1 high-risk feature (67.1%, 82.4%), or stage III disease (59.1%, 68.1%; p < 0.05). Although chemotherapy is associated with improved cause-specific survival in stage III disease, it is associated with worse cause-specific survival in patients with stage II disease.

LIMITATIONS

This study being a retrospective database analysis is the main limitation. Also, lymphovascular invasion, margin status, and clinical obstruction or perforation were absent from the dataset.

CONCLUSIONS

Multiple high-risk features in stage II colon cancer predict worse survival than lymph node metastasis. Chemotherapy is associated with adverse cause-specific survival in patients with stage II disease. Further study into this group should focus on the type and duration of adjuvant therapy and biological features of these tumors. See Video Abstract at http://links.lww.com/DCR/B929 .

MLTIPLES CARACTERSTICAS DE ALTO RIESGO PARA EL CARCINOMA DE COLON EN ESTADIO II PRESAGIAN PEOR SUPERVIVENCIA QUE LA ENFERMEDAD EN ESTADIO III

ANTECEDENTES:Las características de alto riesgo en el cáncer de colon en estadio II empeoran la supervivencia y sirven como impulso para la quimioterapia adyuvante. Existen datos limitados sobre el efecto de múltiples características de alto riesgo en la supervivencia.OBJETIVO:Comparar la supervivencia de cero, una o múltiples características de alto riesgo en el cáncer de colon en estadio II con la enfermedad en estadio III.DISEÑO:Los pacientes con cáncer de colon en estadio II y III diagnosticados entre 2010 y 2016 se identificaron mediante la base de datos de supervivencia, epidemiología y resultados finales. Luego, los pacientes en etapa II se clasificaron según la presencia de cero, 1 o 2+ de las siguientes características de alto riesgo: T4 patológico, invasión perineural, menos de 12 ganglios linfáticos evaluados (< 12 ganglios linfáticos) o mala diferenciación histológica. Se calculó la supervivencia observada y específica de la causa. Luego, cada grupo se estratificó en función de si se administró quimioterapia.ESCENARIO:Este estudio utilizó la base de datos de supervivencia, epidemiología y resultados finales, 2010-2016.PACIENTES:Los pacientes tenían cáncer de colon en estadio II o III.PRINCIPALES MEDIDAS DE RESULTADO:La medida principal fue la supervivencia observada a 5 años y la supervivencia por causa específica.RESULTADOS:Se estudiaron un total de 65,831 pacientes. 18,056 pacientes estaban en estadio II sin características de alto riesgo, 9.426 con 1 característica de alto riesgo y 3.503 con 2+ características de alto riesgo. Hubo 34.842 pacientes a los que se les diagnosticó enfermedad en estadio III. La supervivencia observada a los 5 años y la supervivencia específica de la causa para los pacientes con cáncer en estadio II con 2+ características de alto riesgo (49.2 %, 59.5 %) fueron más bajas, en comparación con aquellos sin características de alto riesgo (74.9 %, 90.7 %), con 1 característica de alto riesgo (67.1 %, 82.4 %) o enfermedad en estadio III (59.1 %, 68.1 %) (p < 0.05). Si bien la quimioterapia se asocia con una mejor supervivencia por causa específica en la enfermedad en estadio III, se asocia con una peor supervivencia por causa específica en pacientes con enfermedad en estadio II.LIMITACIONES:Este es un análisis de base de datos retrospectivo. La invasión linfovascular, el estado de los márgenes y la obstrucción o perforación clínicas estaban ausentes en la base de datos.CONCLUSIONES:Múltiples características de alto riesgo en el cáncer de colon en estadio II predicen una peor supervivencia que la metástasis en los ganglios linfáticos. La quimioterapia se asocia con una supervivencia específica de causa adversa en pacientes con enfermedad en estadio II. El estudio adicional de este grupo deberá centrarse en el tipo y la duración de la terapia adyuvante y las características biológicas de estos tumores. Consulte Video Resumen en http://links.lww.com/DCR/B929 . (Traducción-Dr. Jorge Silva Velazco ).

Abstract 6315: Are a subset of patients at higher risk for mortality in stage III colon cancer: An analysis of the SEER database

Background: High-risk features (HRF) increase mortality for Stage II colon cancer (CC). These HRF include pathologic T4 disease, perineural invasion (PNI), lymphovascular invasion (LVI), an inadequate lymphadenectomy (less than 12 lymph nodes harvested) and poorly differentiated tumors. The presence of two or more HRF has an additive impact on survival for patients with Stage II CC. While T4 and disease greater than N1a raise the risk of mortality in Stage III CC, the effect of the other accepted HRF in patients with Stage III CC has not been studied.

Materials and Methods: Surveillance, Epidemiology and End Results (SEER) (2010 - 2017) was used to identify patients with Stage III and IV CC. Patients with Stage III CC were then further classified by the presence of zero, 1, or 2 or more of the following HRF: pathologic T4, PNI, inadequate lymphadenectomy, or poor differentiation. Overall (OS) and cause-specific (CS) survival were calculated.

Results: 57,640 patients with Stage III or IV CC were identified. 35,760 (62%) patients had Stage III disease and 21,880 (38%) had Stage IV disease. Among patients with Stage III disease, 16,733 (46.8%) had no HRF, 12,703 (35.5%) had 1 HRF and 6,324 (17.7%) had 2 or more HRF. For patients with 1 HRF, 4,610 (36.3%) had poor differentiation, 2,339 (18.4%) had PNI, 3,673 (28.9%) had T4 disease, and 2,078 (16.4%) had an inadequate nodal harvest. Patients with Stage III CC without HRF had the best OS (73.3%) and CS (81.4%,). This was followed by Stage III with 1 HRF (OS 63.7%, CS 71.6%) and Stage III with 2 or more HRF (OS 44%, CS 51%). Patients with Stage IV disease had the worst OS (18.1%) and CS (20.4%) (p&lt;0.05). For patients with 1 HRF, pathologic T4 conferred worse OS (57.2%) and CS (63.2%), compared to PNI (OS 66.4%, CS 73.7%), inadequate lymphadenectomy (OS 64.6%, CS 74.9%) and poor differentiation (OS 66.6%, CS 75.4%) (p&lt;0.01).

Conclusion: HRF have a cumulative influence on OS and CS in patients with Stage III CC. The presence of multiple HRF should be considered higher risk for patients with Stage III disease.

Citation Format: Luv N. Hajirawala, Yong Yi, Michelle A. Bergeron, Danielle A. Dooley, Guy R. Orangio, Elyse R. Bevier-Rawls, Kurt G. Davis, Jeffrey S. Barton. Are a subset of patients at higher risk for mortality in stage III colon cancer: An analysis of the SEER database [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6315.

Minimally Invasive Surgery is Associated with Improved Outcomes Following Urgent Inpatient Colectomy

Objectives

The use of minimally invasive techniques for urgent colectomies remains understudied. This study compares short-term outcomes following urgent minimally invasive colectomies to those following open colectomies.

Methods & Procedures

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) colectomy database was queried between January 1, 2013 and December 31, 2018. Patients who underwent elective and emergency colectomies, based on the respective NSQIP variables, were excluded. The remaining patients were divided into two groups, minimally invasive surgery (MIS) and open. MIS colectomies with unplanned conversion to open were included in the MIS group. Baseline characteristics and 30-day outcomes were compared using univariable and multivariable regression analyses.

Results

A total of 29,345 patients were included in the study; 12,721 (43.3%) underwent MIS colectomy, while 16,624 (56.7%) underwent open colectomy. Patients undergoing MIS colectomy were younger (60.6 vs 63.8 years) and had a lower prevalence of either American Society of Anesthesiology (ASA) IV (9.9 vs 15.5%) or ASA V (0.08% vs 2%). After multivariable analysis, MIS colectomy was associated with lower odds of mortality (odds ratio = 0.75, 95% confidence interval: 0.61, 0.91 95% confidence interval), and most short-term complications recorded in the ACS NSQIP. While MIS colectomies took longer to perform (161 vs 140 min), the length of stay was shorter (12.2 vs 14.1 days).

Conclusions

MIS colectomy affords better short-term complication rates and a reduced length of stay compared to open colectomy for patients requiring urgent surgery. If feasible, minimally invasive colectomy should be offered to patients necessitating urgent colon resection.

Laparoscopic Colectomy for Acute Diverticulitis in the Urgent Setting is Associated with Similar Outcomes to Open

PURPOSE/BACKGROUND

The role of minimally invasive surgery (MIS) for the surgical treatment of diverticular disease is evolving. The aim of this study is to compare the outcomes of MIS colectomy to those of open surgery for patients with acute diverticulitis requiring urgent surgery.

METHODS

The American college of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing an urgent colectomy for acute diverticulitis between 2013 and 2018. The patients were then divided into 2 groups: MIS and open. Baseline characteristics and short-term outcomes were compared using univariable and multivariable regression analyses.

RESULTS/OUTCOMES

3487 patients were included in the analysis. Of these, 1272 (36.5%) underwent MIS colectomy and 2215 (63.5%) underwent open colectomy. Patients undergoing MIS colectomy were younger (58.7 vs 61.9 years) and less likely to be American Society of Anesthesiologists Classification (ASA) III (52.5 vs 57.9%) or IV (6.3 vs 10.5%). After adjusting for baseline differences, the odds of mortality for MIS and open groups were similar. While there was no difference in short-term complications between groups, the odds of developing an ileus were lower following MIS colectomy (OR .61, 95% CI: .49, .76). Both total length of stay (LOS) (12.3 vs 13.9 days) and post-operative LOS (7.6 days vs 9.5 days) were shorter for MIS colectomy. Minimally invasive surgery colectomy added an additional 40 minutes of operative time (202.2 vs 160.1 min).

CONCLUSION/DISCUSSION

Minimally invasive surgery colectomy appears to be safe for patients requiring urgent surgical management for acute diverticulitis. Decreased incidence of ileus and shorter LOS may justify any additional operative time for MIS colectomy in suitable candidates.

Trends in Open, Laparoscopic, and Robotic Approaches to Colorectal Operations

The use of robotic approach has gained momentum in colorectal surgery. We analyzed the trends in the adoption of robotic-assisted platform (RAP) for colorectal surgery over a 6-year period (2013-2018) using the American College of Surgeons National Surgical Quality Improvement Project. We assessed yearly prevalence of robotic, laparoscopic, and open approaches, and evaluated trends in the adoption of RAP across age, gender, BMI, and American Society of Anesthesiology (ASA) subgroups. Overall, the frequency of open, laparoscopic, and robotic approach was 36%, 46.8%, and 7.8%, respectively. While the use of laparoscopic cases remained stable over the study period, the prevalence of RAP increased from 2.8% to 11.4%. This was accompanied by a concomitant decline in the use of open approach, from 40.8% to 33%. The use of RAP also increased across all age, gender, BMI, and ASA subgroups. Robotic-assisted platform is increasingly utilized for higher risk, older, and obese patients, allowing more patients to receive minimally invasive colorectal surgery.

Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review

BACKGROUND

The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof.

METHOD

Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan-guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30-90 days of index admission. Data were stratified by three arbitrary time intervals: 1986-2000, 2000-2010, and after 2010. The primary outcome was calculated for those groups and compared.

RESULTS

Thirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000-2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%).

CONCLUSION

This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.

College of American Pathologists Tumor Regression Grading System for Long-Term Outcome in Patients with Locally Advanced Rectal Cancer

BACKGROUND

The National Comprehensive Cancer Network's Rectal Cancer Guideline Panel recommends American Joint Committee of Cancer and College of American Pathologists (AJCC/CAP) tumor regression grading (TRG) system to evaluate pathologic response to neoadjuvant chemoradiotherapy for locally advanced rectal cancer (LARC). Yet, the clinical significance of the AJCC/CAP TRG system has not been fully defined.

MATERIALS AND METHODS

This was a multicenter, retrospectively recruited, and prospectively maintained cohort study. Patients with LARC from one institution formed the discovery set, and cases from external independent institutions formed a validation set to verify the findings from discovery set. Overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were assessed by Kaplan-Meier analysis, log-rank test, and Cox regression model.

RESULTS

The discovery set (940 cases) found, and the validation set (2,156 cases) further confirmed, that inferior AJCC/CAP TRG categories were closely /ccorrelated with unfavorable survival (OS, DFS, LRFS, and DMFS) and higher risk of disease progression (death, accumulative relapse, local recurrence, and distant metastasis) (all p < .05). Significantly, pairwise comparison revealed that any two of four TRG categories had the distinguished survival and risk of disease progression. After propensity score matching, AJCC/CAP TRG0 category (pathological complete response) patients treated with or without adjuvant chemotherapy displayed similar survival of OS, DFS, LRFS, and DMFS (all p > .05). For AJCC/CAP TRG1-3 cases, adjuvant chemotherapy treatment significantly improved 3-year OS (90.2% vs. 84.6%, p < .001). Multivariate analysis demonstrated the AJCC/CAP TRG system was an independent prognostic surrogate.

CONCLUSION

AJCC/CAP TRG system, an accurate prognostic surrogate, appears ideal for further strategizing adjuvant chemotherapy for LARC.

IMPLICATIONS FOR PRACTICE

The National Comprehensive Cancer Network recommends the American Joint Committee of Cancer and College of American Pathologists (AJCC/CAP) tumor regression grading (TRG) four-category system to evaluate the pathologic response to neoadjuvant treatment for patients with locally advanced rectal cancer; however, the clinical significance of the AJCC/CAP TRG system has not yet been clearly addressed. This study found, for the first time, that any two of four AJCC/CAP TRG categories had the distinguished long-term survival outcome. Importantly, adjuvant chemotherapy may improve the 3-year overall survival for AJCC/CAP TRG1-3 category patients but not for AJCC/CAP TRG0 category patients. Thus, AJCC/CAP TRG system, an accurate surrogate of long-term survival outcome, is useful in guiding adjuvant chemotherapy management for rectal cancer.

Delayed Surgery Does Not Increase Risk in Urgent Colectomy for Ulcerative Colitis

BACKGROUND

Medical management is the cornerstone of therapy for ulcerative colitis (UC). In the setting of fulminant disease, hospitalized patients may undergo medical rescue therapy (MRT) or urgent surgery. We hypothesized that delayed attempts at MRT result in increased morbidity and mortality following urgent surgery for UC.

OBJECTIVE

The aim is to assess the outcomes for patients requiring urgent, inpatient surgery for UC in a prompt or delayed fashion.

DESIGN

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) general and colectomy-specific databases from 2013 to 2016 were queried. Urgent surgery was defined as nonelective, nonemergency surgery. Patients were divided into prompt and delayed groups based on time from admission to surgery of <48 hours or >48 hours. Baseline characteristics and 30-day outcomes were compared using univariate and multivariate analyses.

SETTING

The ACS NSQIP database from 2013 to 2016 was evaluated.

PATIENTS

Adult patients undergoing nonelective, nonemergency colectomy for UC.

MAIN OUTCOME MEASURES

30-day morbidity and mortality.

RESULTS

921 patients underwent urgent inpatient surgery for UC. In univariate analysis, there was no significant difference between prompt and delayed surgery for wound infection, sepsis, return to operating room, or readmission.

LIMITATIONS

Retrospective study of a quality improvement database. Patients who underwent successful MRT did not receive surgery, so are not included in the database.

CONCLUSIONS

Delaying surgery to further attempt MRT does not alter short-term outcomes and may allow conversion to elective future surgery. Contrarily, medical optimization does not improve short-term outcomes.

The Impact of a Colorectal Care Bundle for Surgical Site Infections at an Academic Disproportionate Share Hospital With a Level I Trauma Center

OBJECTIVES

Colorectal care bundles for surgical site infections (CRCB-SSIs) have been shown to reduce SSIs following elective colorectal surgery (CRS). There are limited data evaluating the effect of CRCB-SSI at Academic Disproportionate Share Hospitals (ADSH) with significant rates of urgent and emergent cases.

METHODS

A CRCB-SSI was implemented in April 2016. We reviewed medical records of all patients undergoing colon resections between August 2015 and December 2017. Patients were divided into preimplementation and postimplementation groups. The primary endpoint was the SSI rate, and the secondary endpoint included types of SSI (superficial, deep, organ space). Univariable and multivariable analyses were performed. A subset analysis was performed in elective cases.

RESULTS

We analyzed a total of 417 patients. Of these, 116 (28%) and 301 (72%) patients were in the preimplementation and postimplementation groups, respectively. The rate of SSI decreased from 30.1% to 15.9% in the postimplementation group (P = .0012); however, it was not statistically significant after adjusting for baseline differences (relative risk [RR] 0.65; 95% CI 0.41-1.02).The elective subset included 219 patients. The rate of SSI in this cohort decreased from 25% to 10.5% in the postimplementation group (P = .0012) and remained significant following multivariable analysis (RR 0.41, 95% CI 0.19- 0.88). There were no differences in the subtypes of SSI.

DISCUSSION

While the CRCB-SSI was effective in decreasing the postoperative SSI rate for elective cases, its effect on the overall patient population was limited. CRCB-SSIs are not enough to bring SSI rates to accepted rates in high-risk patients such as those seen at ADSH.

Clinical efficacy and quality of life after transrectal natural orifice specimen extraction for the treatment of middle and upper rectal cancer

Background

Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) avoids extra abdominal extraction incision during colorectal surgery. Some surgeons realized the benefits of NOSE on clinical efficacy. We compared the clinical efficacy of laparoscopic NOSE, laparoscopic non-NOSE and open surgery (OS) for short-term recovery and quality of life (QoL).

Methods

A single randomized controlled trial of NOSE for middle and upper rectal cancer between April 2014 and February 2018. Preoperative and postoperative clinical variables were analyzed and compared between the groups. Preoperative and 6 months postoperative QoL was assessed with the SF-36 QoL questionnaire.

Results

A total of 378 patients were enrolled, 334 patients randomly divided into NOSE group (n=104), non-NOSE group (n=119), OS group (n=111). The NOSE group was superior to the other two groups on the QoL after surgery. The NOSE group had the lowest postoperative VAS score between three groups. The postoperative time for bowel function recovery and the length of hospital stay was statistically significantly different among the three groups, with the NOSE group having the shortest time. The incidence of postoperative complications was lower in the NOSE group (12/104, 11.5%) than in the non-NOSE group (20/119, 16.8%), the difference was statistically significant. The Kaplan-Meier (K-M) survival curve showed no statistically significant difference in the disease-free survival (DFS) rate between the three groups.

Conclusions

Comparing NOSE to non-NOSE and OS, the NOSE had significantly better functional recovery and better QoL. The NOSE group had a significant lower surgical complication rate than the non-NOSE group.

International Consensus Definition of Low Anterior Resection Syndrome

BACKGROUND

Low anterior resection syndrome is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The low anterior resection syndrome score was designed as a simple tool for clinical evaluation of low anterior resection syndrome. Although the low anterior resection syndrome score has good clinical utility, it may not capture all important aspects that patients may experience.

OBJECTIVE

The aim of this collaboration was to develop an international consensus definition of low anterior resection syndrome that encompasses all aspects of the condition and is informed by all stakeholders.

DESIGN

This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting.

PARTICIPANTS

Three expert groups participated: patients, surgeons, and other health professionals from 5 regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in 3 languages (English, Spanish, and Danish).

MAIN OUTCOME MEASURE

The primary outcome measured was the priorities for the definition of low anterior resection syndrome.

RESULTS

Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96%, and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to 8 symptoms and 8 consequences that capture essential aspects of the syndrome.

LIMITATIONS

Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this.

CONCLUSIONS

This is the first definition of low anterior resection syndrome developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of low anterior resection syndrome. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in low anterior resection syndrome over time and with intervention.

International consensus definition of low anterior resection syndrome

AIM

Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders.

METHOD

This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish, and Danish). The primary outcome measured was the priorities for the definition of LARS.

RESULTS

Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this.

CONCLUSION

This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.

International consensus definition of low anterior resection syndrome

BACKGROUND

Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders.

METHODS

This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish and Danish). The primary outcome measured was the priorities for the definition of LARS.

RESULTS

Three hundred and twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this.

CONCLUSIONS

This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.

Basic Science, Epidemiology, and Screening for Anal Intraepithelial Neoplasia and Its Relationship to Anal Squamous Cell Cancer

Despite the progress made in the reduction of squamous cell carcinoma of the cervix, the incidence of anal squamous cell carcinoma (ASCC) has been increasing since 1992. While it remains an uncommon disease, the prevalence is climbing steadily. Among human immunodeficiency virus (HIV)-infected adults, especially men who have sex with men, ASCC is one of the more common non-AIDS-defining malignancies. The precursor lesion, anal intraepithelial neoplasia (AIN), is prevalent in the HIV-infected population. More than 90% of ASCCs are related to human papilloma virus (HPV), oncogenic types (HPV 16, 18). While the biology of HPV-related intraepithelial neoplasia is consistent in the anogenital area, the natural history of AIN is poorly understood and is not identical to cervical intraepithelial neoplasia (CIN). CIN is also considered an AIDS-defining malignancy, and the methods for screening and prevention of AIN are derived from the CIN literature. This article will discuss the epidemiology of ASCC and its association with HPV and the life cycle of the HPV, and the molecular changes that lead to clearance, productive infection, latency, and persistence. The immunology of HPV infection will discuss natural immunity, humoral and cellular immunity, and how the HPV virus evades and interferes with these mechanisms. We will also discuss high-risk factors for developing AIN in high-risk patient populations with relation to infections (HIV, HPV, and chlamydia infections), prolonged immunocompromised people, and sexual behavior and tobacco abuse. We will also discuss the pre- and post-HAART era and its effect on AINs and ASCC. Finally, we will discuss the importance of anal cytology and high-resolution anoscopy with and without biopsy in this high-risk population.

The Economics of Colon Cancer

The economic burden of cancer on the national health expenditure is billions of dollars. The economic cost is measured on direct and indirect medical costs, which vary depending on stage at diagnosis, patient age, type of medical services, and site of service. Costs vary by region, physician behavior, and patient preferences. When analyzing the economic burden of survivors of colon cancer, we cannot forget the societal burden. Post-acute care and readmissions are major economic burdens. People with colon cancer have to be followed for their lifetime. Economic models are being studied to give cost-effective solutions to this problem.

Current status: new technologies for the treatment of patients with fecal incontinence

Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. Treatment is often challenging and needs to be individualized. During the last several years, new technologies have been developed, and others are emerging from clinical trials to commercialization. Although their specific roles in the management of fecal incontinence have not yet been completely defined, surgeons have access to them and patients may request them. The purpose of this project is to put into perspective, for both the patient and the practitioner, the relative positions of new and emerging technologies in order to propose a treatment algorithm.

Enterocutaneous fistula: medical and surgical management including patients with Crohn's disease

Patients with inflammatory bowel disease (IBD) and especially Crohn's disease can be challenging for even the most seasoned of surgeons. Development of an enterocutaneous fistula (ECF) in these patients further adds a level of complexity that requires a well-planned and defined management strategy. The role of the surgeon in caring for these patients should be as the leader of a multidisciplinary team, directing the care of the other specialists, all while determining if, and when, the patient requires operative intervention. Although medical management has come a long way in these and similar patients, surgery is still needed in a vast majority of patients. Therefore, understanding the evaluation, initial management, and important technical considerations for care of IBD and other complex patients with ECFs is a difficult, yet much needed, task for which the surgeon should be prepared.

Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up

PURPOSE

The long-term efficacy of Surgisis anal fistula plug in closure of cryptoglandular anorectal fistulas was studied.

METHODS

Patients with high cryptoglandular anorectal fistulas were prospectively studied. Additional variables recorded were: number of fistula tracts, and presence of setons. Under general anesthesia and in prone jackknife position, patients underwent irrigation of the fistula tract by using hydrogen peroxide. Each primary opening was occluded by using a Surgisis anal fistula plug, which was securely sutured in place at the primary opening and tacked to the periphery of the secondary opening.

RESULTS

Forty-six patients were prospectively enrolled during a two-year period. Follow-up was six months to two years (median, 12 months). At final follow-up, all fistula tracts had been successfully closed in 38 patients, for an overall success rate of 83 percent. Seven patients had multiple tracts, for a total of 55 fistula tracts in the series. Of the 55 individual tracts, 47 (85 percent) were closed at final follow-up. Patients with one primary opening were most likely to have successful closure by using the anal fistula plug, although this was not significant. Successful closure was not correlated with the presence of setons.

CONCLUSIONS

Long-term closure of cryptoglandular anorectal fistula tracts using Surgisis anal fistula plug is safe and successful in 83 percent of patients and 85 percent of tracts.

Efficacy of anal fistula plug in closure of Crohn's anorectal fistulas

PURPOSE

The efficacy of Surgisis anal fistula plug in closure of Crohn's anorectal fistula was studied.

METHODS

Patients with Crohn's anorectal fistulas were prospectively studied. Diagnosis was made by histologic, radiographic, or endoscopic criteria. Variables recorded were: number of fistula tracts (primary openings), presence of setons, and current antitumor necrosis factor therapy. Under general anesthesia and in prone jackknife position, patients underwent irrigation of the fistula tract by using hydrogen peroxide. Each primary opening was occluded by using a Surgisis anal fistula plug. Superficial tracts amenable to fistulotomy were excluded.

RESULTS

Twenty consecutive patients were prospectively enrolled, comprising a total of 36 fistula tracts. At final follow-up, all fistula tracts had been successfully closed in 16 of 20 patients, for an overall success rate of 80 percent. Thirty of 36 individual fistula tracts (83 percent) were closed at final follow-up. Patients with single fistulas (with 1 primary opening) were most likely to have successful closure using the anal fistula plug. Successful closure was not correlated with the presence of setons or antitumor necrosis factor therapy.

CONCLUSIONS

Closure of Crohn's anorectal fistula tracts using Surgisis anal fistula plug is safe and successful in 80 percent of patients and 83 percent of fistula tracts. Closure rates were higher with single tracts than complex fistulas with multiple primary openings.

Factors associated with complications of open versus laparoscopic sigmoid resection for diverticulitis

BACKGROUND

This study critically reviews sigmoid colon resection for diverticulitis comparing open and laparoscopic techniques.

METHODS

We conducted a retrospective review of all open and laparoscopic cases of diverticulitis between 1992 and 2001. Data analyzed included the following: indications for operation, postoperative complications, and incidence of laparoscopic conversion to laparotomy. Major and minor complications were analyzed in relation to patients' preoperative diagnosis, age, presence or absence of splenic flexure mobilization, length of stay, and laparoscopic sigmoid resection versus open sigmoid resection.

RESULTS

Over a 10-year period, 166 resections for diverticulitis were performed including 126 open cases and 40 laparoscopic cases. No significant differences existed in patient characteristics between the groups. Major complications occurred in 14% of patients, and the laparoscopic conversion rate was 20%. The presence of abscess, fistula, or stricture preoperatively was associated with a higher complication rate only in patients > or =50 years old undergoing open sigmoid resection. The length of stay between patients undergoing laparoscopic resection was significantly less than in patients having open resection.

CONCLUSION

Advanced laparoscopic sigmoid resection is an alternative to open sigmoid resection in patients with diverticulitis and its complications. Open sigmoid resection in patients >50 years may have a higher complication rate in complicated diverticulitis when compared with laparoscopic sigmoid resection (all patient ages) and open sigmoid resection (patients <50 years old). Regarding complications, no difference existed between the length of stay in patients with open vs. laparoscopic resection.

Harmonic scalpel hemorrhoidectomy: five hundred consecutive cases

PURPOSE

The aim of this study was to evaluate the incidence of postoperative complications after Harmonic Scalpels hemorrhoidectomy and to identify any predisposing factors leading to postoperative complications.

METHODS

Five hundred consecutive cases of Harmonic Scalpel hemorrhoidectomy were studied in a prospective manner. Postoperative complications were recorded, and any predisposing factors were evaluated.

RESULTS

Three hundred fifty-five patients (71 percent) underwent Harmonic Scalpel hemorrhoidectomy alone. One hundred twenty patients (24 percent) underwent additional fissurectomy/sphincterotomy for fissure-in-ano, and 25 patients (5 percent) underwent additional fistulotomy. A total of 24 (4.8 percent) patients experienced some form of postoperative complication. Three patients (0.6 percent) experienced a secondary postoperative hemorrhage requiring reexploration under anesthesia. Two of the three patients were taking postoperative oral Toradol, and both had undergone an "open" hemorrhoidectomy technique. The third patient required suture ligation of multiple bleeding sites on two separate occasions at 7 and 14 days postoperatively. The patient was subsequently diagnosed as having Ehlers-Danlos syndrome. One patient experienced postoperative incontinence to flatus and stool. The patient had large, Grade TV postpartum hemorrhoids and had undergone a three-quadrant closed hemorrhoidectomy. The sphincter mechanism was intact on postoperative ultrasound, and an underlying pudendal neuropathy likely contributed to the sphincter dysfunction. Postoperative urinary retention was noted in 10 (2 percent) patients, postoperative fissure in 5 (1 percent), and abscess/fistula in 4 (0.8 percent). One patient (0.2 percent) required readmission for colonic pseudo-obstruction.

CONCLUSION

Harmonic Scalpel hemorrhoidectomy is a safe surgical modality, and postoperative complication rates compare favorably with previously published studies. The combination of an "open" hemorrhoidectomy technique and prolonged oral Toradol administration may result in a higher incidence of postoperative hemorrhage.

Harmonic Scalpel vs. electrocautery hemorrhoidectomy: a prospective evaluation

INTRODUCTION

Management of posthemorrhoidectomy pain remains a very unsatisfactory clinical dilemma. Compared with electrocautery and laser, the Harmonic Scalpel causes minimal lateral thermal injury during tissue dissection.

PURPOSE

The aim of the study was to establish whether decreased lateral thermal injury translated into diminished posthemorrhoidectomy pain.

METHODS

A prospective randomized trial comparing Harmonic Scalpel hemorrhoidectomy and electrocautery was undertaken. Fifty consecutive patients were randomized into two groups: Harmonic Scalpels and electrocautery hemorrhoidectomy. The indications included Grade III internal hemorrhoids with external components or Grade IV disease. Patients with additional anorectal pathology (fissure or fistula) were excluded, as were patients with neurologic deficits, chronic pain syndrome, and those already taking narcotic analgesics. Pain was assessed using a visual analog scale preoperatively and on postoperative Days 1, 2, 7, 14, and 28. Twenty-four-hour narcotic usage (Hydrocodone, 10 mg) was recorded on postoperative Days 1, 2, 7, 14, and 28. A three-quadrant modified Ferguson hemorrhoidectomy was performed with each patient in the prone jackknife position.

RESULTS

Pain in the Harmonic Scalpel hemorrhoidectomy group was significantly less than in electrocautery patients on each postoperative day studied. Analgesic requirements were also significantly less in the Harmonic Scalpel group on Days 1, 2, 7, and 14. There was no correlation between postoperative pain and grade of hemorrhoid, status of the surgical incision (open vs. closed), or any other study variable. Fifty-five percent of Harmonic Scalpel patients returned to work within one week of surgery, compared with 23 percent of electrocautery patients.

CONCLUSION

The study demonstrates significantly reduced postoperative pain after Harmonic Scalpel hemorrhoidectomy compared with electrocautery controls. The diminished postoperative pain in the Harmonic Scalpel group likely results from the avoidance of lateral thermal injury.

Surgical options for familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is a genetic disorder transmitted in an autosomal dominant pattern. One-half of members of an affected family will carry the gene, and all carriers will succumb to colon cancer or extracolonic manifestations if not detected and treated early. When the diagnosis is made, surgery is indicated. Surgical options include total proctocolectomy with ileostomy, continent ileostomy, total colectomy with ileorectal anastomosis, and total proctocolectomy with ileal pouch anal anastomosis. Many diverse factors, such as extent of rectal disease, the presence and extend of carcinoma, sphincter function, and extracolonic disease, influence which surgical procedure is most appropriate for the individual patient with FAP. This article reviews the surgical options for treating FAP, with emphasis on specific indications, contraindications, and anticipated outcomes.

Laparoscopically assisted bowel surgery. Analysis of 114 cases

In order to help determine the risks and benefits, we retrospectively analyzed the results of our first 114 laparoscopically assisted bowel procedures. Procedures performed consisted of partial colectomy (85), total or subtotal abdominal colectomy (8), total proctocolectomy with J-pouch ileal reservoir (11), and diverting procedures (10). Forty-nine procedures were for malignancy. The rate of conversion to laparotomy was 13.2%. Oral feedings were resumed in 2.4 days (range 1-5), and bowel function returned in 3.8 days (range 2-8). The average length of stay was 4.2 days for partial colectomy and 6 days for total, subtotal, and proctocolectomy. The mean return to normal activity for all groups was 16.7 days (10.8 days for partial colectomy). There were no deaths. Major morbidity (6%) consisted of abscess (3), anastomotic leak (2), and hemorrhage (1). Mean operative costs analyzed for the initial 37 patients were higher for laparoscopic colectomies when compared to traditional colectomies; however, the mean total hospital costs were less for the laparoscopic procedures. These data suggest that the laparoscopic approach to colorectal resection is an acceptable alternative to laparotomy for a variety of disease processes, allowing patients an early return to normal activity.

Laparoscopic surgery for colorectal neoplasms

Laparoscopy is being used to assist in an increasing number and variety of bowel procedures. However, when being used for neoplastic disease concerns of margins and adequacy of mesenteric dissection must be addressed. We've performed 110 laparoscopic-assisted bowel procedures, with 45 of these performed for neoplastic disease. Ninety-two bowel resections were performed including 24 subtotal, total, or proctocolectomies. In this chapter we review the results of our series, as well as other reported series, and discuss some of the controversies involved with laparoscopy for neoplastic disease.

Management of hemophilia in colon and rectal surgery. Report of a patient with factor VIII inhibitors and review of the literature

With the introduction of Factor VIII concentrates, surgery on patients with hemophilia has become possible. The mortality in recent large series is zero. The morbidity has been variable, with postoperative hemorrhage the most common complication. There is a dramatic change in therapeutic strategy with the development of Factor VIII inhibitors. In reviewing the literature, there are no reports discussing this patient population with respect to the subspecialty of colon and rectal surgery. The authors present a report of a patient with hemophilia who, after hemorroidectomy, developed Factor VIII inhibitors and continued hemorrhage. This article also reviews the literature and centralizes the management of colon and rectal surgery patients with hemophilia.

Diffuse cavernous hemangioma of the rectosigmoid--CT scan, a new diagnostic modality, and surgical management using sphincter-saving procedures. Report of three cases

Diffuse cavernous hemangioma of the rectosigmoid is a rare lesion. Preoperative recognition has been recorded but, because of lack of awareness and inconsistent diagnoses, inappropriate therapy still persists. Surgical therapy is the hallmark of treatment. Abdominoperineal resection has been advocated. Three cases of diffuse cavernous hemangiomas of the rectosigmoid, recognized preoperatively and treated successfully with sphincter-saving procedures, are reported. Use of the CT scan as a consistent diagnostic tool will be presented for the first time.

The Chilaiditi syndrome and associated volvulus of the transverse colon. An indication for surgical therapy

Hepatodiaphragmatic interposition of the colon is a rare anomaly described by Chilaiditi in 1910. Usually this syndrome presents as an asymptomatic roentgen finding, although occasionally it is associated with a broad range of gastrointestinal symptoms. The hallmark of therapy is conservative, and rarely has surgical intervention been indicated. This is the only case report of the Chilaiditi syndrome associated with colonic volvulus. It also illustrates the rare progression of colonic interposition from mild abdominal discomfort to intermittent bowel obstruction requiring surgical intervention.

A new type of continent ileostomy. Results of an animal study

Kock's continent ileostomy is a well-established technique, however, it is technically difficult to construct and has a high incidence of complications. This study evaluates a new type of mucosal valve constructed in continuity with an intestinal reservoir. The valve is created along the antimesenteric border of the efferent limb 0.5 cm distal to the reservoir. The seromuscular layer is "stripped" from the mucosal layer for 50 per cent of the bowel circumference and then excised. The remaining seromuscular borders are then sutured to the apex of the pouch and along the antimesenteric border of the afferent limb. In this way the valve is created and, upon distention of the afferent limb and apex of the pouch, the valve closes. In seven dogs such a continent ileostomy was constructed and all were clinically continent. The reservoirs were intubated through the ileostomy two to three times a day. The mean volume aspirated was 143 ml/day. After eight weeks, radiographic and volume-pressure studies were performed. Prior to sacrifice, increasing volumes of barium were instilled into each pouch via the afferent limb and radiographs were taken: these studies confirmed the continence in all seven ileostomies. Following this the reservoirs were intubated and the instilled barium was aspirated. Then Ringer's solution was instilled into each pouch with continuous intrapouch pressure measurements. The pressure remained at 0 cmH2O until a mean volume of 243 ml was exceeded. The mean volume at which incontinence occurred was 415 ml.

Soft tissue infections in parenteral drug abusers

Thirty-four parenteral drug abusers admitted with soft tissue infections underwent bacteriologic and immunologic evaluation. Staphylococcus aureus and beta hemolytic streptococci were the most common organisms recovered. Enteric gram negative aerobes and oral flora were common and enteric anaerobes rare. Absolute lymphopenia and elevations in the IgA, IgG and IgM fractions of the immunoglobulins were common as were false positive VDRL examinations. Cutaneous anergy was found in 83% of the group and 70% of a simultaneously noninfected addict group. Staphylococcal carriage was frequent. Because of variation in the flora between this and other reported groups, ongoing bacteriologic surveillance could be a useful guide to initial antibiotic therapy. Differences in the pattern of immune reaction in this group when compared to different addict groups suggest a difference in antigenic stimulation, possibly as a result of differences in bacteriologic exposure.

Infections in parenteral drug abusers. Further immunologic studies

In our previous study of soft tissue infections in parenteral drug abusers, two thirds of the infections were polymicrobial. Oral and enteric organisms were frequently recovered. These patients and a group of uninfected addicts showed frequent cutaneous anergy, lymphopenia, and hypergammaglobulinemia. An additional group of uninfected addicts was studied. The mean levels of IgA, IgG, and IgM were higher in the uninfected addicts. In the addict and control groups, elevations in IgA (17 percent of total), IgG (65 percent), and IgM (19 percent) levels were found. Zinc levels were within normal limits. T-cell populations below 70 percent were seen in five of the seven addicts and two of the four control subjects. Reversed helper to suppressor cell ratios were found in three of the seven addicts and control subjects. No consistent pattern of immunologic abnormalities emerged. The interrelationship of the abnormalities in the addict and their relationship to AIDS is unclear.