Prevalence of High-Grade Anal Dysplasia and Anal Cancer in Veterans Living With HIV and CD4/CD8 Ratio as a Marker For Increased Risk: A Regional Retrospective Cohort Study.

BACKGROUND: The Department of Veterans Affairs cares for the largest population of patients with HIV of any healthcare system in the United States. Screening for anal dysplasia/cancer is recommended for all veterans with HIV. Exams are invasive, burdensome, and resource intensive. We currently lack markers of disease to tailor screening. OBJECTIVE: The purpose of this study was to establish the prevalence of advanced anal disease (high-grade dysplasia and anal cancer) and to determine whether CD4/CD8 ratio correlates with risk. DESIGN: This was a retrospective regional cohort study of veterans with HIV. SETTINGS: The study was conducted at eight medical centers between 2001 and 2019. PATIENTS: Patients with advanced disease were compared with patients with nonadvanced anal pathology. MAIN OUTCOME MEASURES: Logistic regression modeling was used to estimate adjusted odds of disease as a function of CD4/CD8. Lowest (nadir) CD4/CD8 and nearest CD4/CD8 ratio in each cohort were evaluated. RESULTS: A total of 2267 veterans were included. Fifteen percent had anal pathology (112 with advanced disease (37 cancer and 75 high-grade), 222 with nonadvanced disease). Nadir and nearest ratio were lower in patients with advanced disease versus nonadvanced (0.24 vs 0.45 (p < 0.001) and 0.50 vs 0.88 (p < 0.001)). In adjusted models, a 1-unit increase in nadir or nearest ratio conferred decreased risk of advanced disease (OR = 0.19 (95% CI, 0.07-0.53); p < 0.001; OR = 0.22 (95% CI, 0.12-0.43); p < 0.001). Using a minimum sensitivity analysis, a cutoff nadir ratio of 0.42 or nearest ratio of 0.76 could be used to risk stratify. LIMITATIONS: This was a retrospective analysis with a low screening rate. CONCLUSIONS: In a regional cohort of veterans with HIV, 15% were formally assessed for anal dysplasia. Advanced anal disease was present in 33% of those screened, 5% of the HIV-positive population. A strong predictor of advanced disease in this cohort is the CD4/CD8 ratio, which is a promising marker to stratify screening practices. Risk stratification using CD4/CD8 has the potential to decrease burdensome invasive examinations for low-risk patients and to intensify examinations for those at high risk. See Video Abstract at http://links.lww.com/DCR/B528. PREVALENCIA DE DISPLASIA ANAL DE ALTO GRADO Y CNCER ANAL EN VETERANOS QUE VIVEN CON EL VIH Y LA RELACIN CD / CD COMO MARCADOR DE MAYOR RIESGO UN ESTUDIO DE COHORTE REGIONAL RETROSPECTIVE: ANTECEDENTES:El Departamento de Asuntos de Veteranos atiende a la población más grande de pacientes con el virus de inmunodeficiencia humana (VIH) de cualquier sistema de salud en los Estados Unidos. Se recomienda la detección de displasia / cáncer anal para todos los veteranos con VIH. Los exámenes son invasivos, onerosos y requieren muchos recursos. Actualmente carecemos de marcadores de enfermedad para adaptar la detección.OBJETIVO:Establecer la prevalencia de enfermedad anal avanzada (displasia de alto grado y cáncer anal) y determinar si la relación CD4 / CD8 se correlaciona con el riesgo.DISEÑO:Estudio de cohorte regional retrospectivo de veteranos con VIH.AJUSTE:Ocho centros médicos entre 2001-2019.PACIENTES:Se comparó a pacientes con enfermedad avanzada con pacientes con patología anal no avanzada.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizó un modelo de regresión logística para estimar las probabilidades ajustadas de enfermedad en función de CD4 / CD8. Se evaluó la relación CD4 / CD8 más baja (nadir) y la relación CD4 / CD8 más cercana en cada cohorte.RESULTADOS:Se incluyeron un total de 2267 veteranos. El 15% tenía patología anal (112 enfermedad avanzada (37 cáncer, 75 de alto grado), 222 enfermedad no avanzada). El nadir y el cociente más cercano fueron menores en los pacientes con enfermedad avanzada frente a los no avanzados (0,24 frente a 0,45 (p <0,001) y 0,50 frente a 0,88 (p <0,001)), respectivamente. En modelos ajustados, el aumento de una unidad en el nadir o el cociente más cercano confirió una disminución del riesgo de enfermedad avanzada (OR 0,19 (IC del 95%: 0,07, 0,53, p <0,001)) y (OR 0,22 (IC del 95%: 0,12, 0,43, p <0,001))), respectivamente. Utilizando un análisis de sensibilidad mínima, se podría utilizar un cociente del nadir de corte de 0,42 o el cociente más cercano de 0,76 para estratificar el riesgo.LIMITACIONES:Análisis retrospectivo con una tasa de detección baja.CONCLUSIONES:En una cohorte regional de veteranos con VIH, el 15% fueron evaluados formalmente por displasia anal. La enfermedad anal avanzada estuvo presente en el 33% de los examinados, el 5% de la población VIH +. Un fuerte predictor de enfermedad avanzada en esta cohorte es la relación CD4 / CD8, que es un marcador prometedor para estratificar las prácticas de detección. La estratificación del riesgo usando CD4 / CD8 tiene el potencial de disminuir los exámenes invasivos onerosos para los pacientes de bajo riesgo e intensificar los exámenes para los de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B528.

Does Anastomotic Leak Contribute to High Failure-to-rescue Rates?

OBJECTIVE: Our aim was to evaluate failure-to-rescue (FTR) after anastomotic leak (AL) in colectomy patients. BACKGROUND: In the era of pay for performance, it is imperative that we understand the quality measures under which we are scrutinized. FTR has been proposed as a marker of surgical quality. We investigated the role of complications in FTR rates in colectomy patients. METHODS: Patients who underwent nonemergent colectomy from 2012 to 2013 were identified from the The American College of Surgeons National Quality Improvement Program (ACS NSQIP database). Mortality after AL was assessed and stratified in relation to mortality after other postoperative complications. χ and logistic regression analysis were used to assess the effect of AL on mortality. RESULTS: We identified 30,101 patients who met inclusion criteria, 1127 suffered an AL (3.7%). FTR was increased in patients with AL compared with those without AL (6% vs 1%, P < 0.001). The mortality rate after leak was similar to mortality after other major complications. Independent risk factors for death after AL included older age (odds ratio [OR] 3.140; 95% confidence interval [CI], 1.744-5.651), cancer diagnosis (OR 2.032; 95% CI, 1.177-3.507), and open approach (OR 2.124; 95% CI, 1.194-3.776) while preoperative bowel preparation was protective (OR 0.563; 95% CI, 0.328-0.969). CONCLUSIONS: AL is a common complication after colectomy with a relatively high FTR rate. As hospitals are penalized for not reaching specific rates of FTR, we must better understand these complex relationships to improve quality and safety of patient care.

Short-term outcomes of minimally invasive versus open colectomy for colon cancer.

BACKGROUND: Laparoscopic and open approaches to colon resection have equivalent long-term outcomes and oncologic integrity for the treatment of colon cancer. Differences in short-term outcomes should therefore help to guide surgeons in their choice of operation. We hypothesized that minimally invasive colectomy is associated with superior short-term outcomes compared to traditional open colectomy in the setting of colon cancer. MATERIALS AND METHODS: Patients undergoing nonemergent colectomy for colon cancer in 2012 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted colectomy participant use file. Patients were divided into two cohorts based on operative approach-open versus minimally invasive surgery (MIS). Univariate, multivariate, and propensity-adjusted multivariate analyses were performed to compare postoperative outcomes between the two groups. RESULTS: A total of 11,031 patients were identified for inclusion in the study, with an overall MIS rate of 65.3% (n = 7200). On both univariate and multivariate analysis, MIS approach was associated with fewer postoperative complications and lower mortality. In the risk-adjusted multivariate analysis, MIS approach was associated with an odds ratio of 0.598 for any postoperative morbidity compared to open (P < 0.001). CONCLUSIONS: This retrospective study of patients undergoing colectomy for colon cancer demonstrates significantly improved outcomes associated with a MIS approach, even when controlling for baseline differences in illness severity. When feasible, minimally invasive colectomy should be considered gold standard for the surgical treatment of colon cancer.

Postoperative complications in patients with rectal cancer are associated with delays in chemotherapy that lead to worse disease-free and overall survival.

OBJECTIVE: The objective of this study was to identify the risk factors for delays in chemotherapy after rectal cancer surgery and evaluate the effects of delayed therapy on long-term outcomes. We also sought to clarify what time frame should be used to define delayed adjuvant chemotherapy. BACKGROUND: Postoperative complications have been found to influence the timing of chemotherapy in patients with colon cancer. Delays in chemotherapy have been shown to be associated with worse overall and disease-free survival in patients with colorectal cancer, although the timing of delay has not been agreed upon in the literature. STUDY DESIGN: We performed a retrospective review of a prospectively maintained rectal cancer database. Univariate analysis was used to identify risk factors for delayed chemotherapy. Kaplan-Meier curves were generated to compare overall and disease-free survival in patients based on complications and timing of chemotherapy. SETTINGS: This study was performed at the University of Wisconsin Hospital, Madison, Wisconsin, between 1995 and 2012. PATIENTS: Patients with rectal cancer who underwent proctectomy with curative intent were included in this study. OUTCOME MEASURES: Timing of chemotherapy, 30-day complications, and 30-day readmissions were the main outcome measures. RESULTS: Postoperative complications and 30-day readmissions were associated with delays in chemotherapy ≥8 weeks after surgery. Patients who received chemotherapy ≥8 weeks postoperatively were found to have worse local and distant recurrence rates and worse overall survival in comparison with patients who received chemotherapy within 8 weeks of surgery. LIMITATIONS: The limitations of this study include its retrospective nature and that it was performed at a single institution. CONCLUSIONS: We found complications and readmissions to be risk factors for delayed chemotherapy. Patients who received therapy ≥8 weeks postoperatively had worse disease-free and overall survival.

Visceral obesity is associated with outcomes of total mesorectal excision for rectal adenocarcinoma.

BACKGROUND AND OBJECTIVES: General obesity, measured by the body mass index (BMI), increases the technical difficulty of total mesorectal excision (TME) but does not affect oncologic outcomes. The purpose of this study is to compare visceral and general obesity as predictors of outcomes of TME for rectal adenocarcinoma. METHODS: Adult patients undergoing TME for rectal adenocarcinoma were retrospectively identified. Preoperative computed tomography scans were used to measure abdominal circumference (AC), visceral (VFA), and subcutaneous fat area (SFA). BMI, AC, VFA, SFA, total fat area (TFA, sum of VFA and SFA), and VFA/SFA ratio were examined for association with operative, postoperative, oncologic, and survival outcomes in a univariate analysis model. RESULTS: Between 1999 and 2009, 113 patients met inclusion criteria. Increasing VFA and VFA/SFA ratio were associated with reduced lymph node retrieval (P = 0.03 and P = 0.009, respectively). The association between increasing VFA/SFA ratio with delayed resumption of oral intake (P = 0.05) and prolonged overall survival (P = 0.003) were also significant. Increasing BMI was associated with improved overall (P = 0.02) but not disease-free survival (P = 0.14). CONCLUSION: Visceral obesity, measured by VFA/SFA ratio, is a better predictor of postoperative, oncologic, and survival outcomes after TME for rectal adenocarcinoma than general obesity measured by the BMI.

Comparable postoperative morbidity and mortality after laparoscopic and open emergent restorative colectomy: outcomes from the ACS NSQIP.

BACKGROUND: Laparoscopic surgery is safe and effective in the management of common abdominal emergencies. However, there is currently a lack of data about its use for emergency colorectal surgery. We hypothesized that laparoscopy can improve the postoperative outcomes of emergency restorative colon resection. METHODS: Adult patients undergoing emergent open and laparoscopic colon resection with primary anastomosis were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005 to 2008 inclusive. Demographic and operative characteristics, laboratory values, and postoperative outcomes were compared between patients undergoing laparoscopic and open colon resection using univariate analyses, multivariate logistic regression, and propensity score analyses. RESULTS: A total of 341 laparoscopic (9.6 %) and 3211 (90.4 %) open colon resections were included. Patients undergoing laparoscopic surgery had a significantly lower prevalence of co-morbidities and better postoperative outcomes. On multivariate analysis, laparoscopic surgery was an independent predictor of a longer operating time (p < 0.001) and shorter total (p = 0.013) and postoperative (p = 0.004) hospital stays, but it did not affect the need for intraoperative blood transfusion (p = 0.488), the 30-day reoperation rates (p = 0.969), or mortality (p = 0.417). After adjusted propensity score analysis, postoperative morbidity (p = 0.833) and mortality (p = 0.568) were comparable in patients undergoing laparoscopic and open surgery. CONCLUSIONS: On a national scale, laparoscopic emergent colon resections are being performed in a small number of patients, who have favorable co-morbidity characteristics and improved postoperative outcomes. Laparoscopic emergent colon resection with primary anastomosis has postoperative morbidity and mortality rates comparable to those seen with the open approach, and it reduces the total and postoperative length of hospital stay.

Optimizing surgical care of colon cancer in the older adult population.

OBJECTIVE: We have undertaken the current study to evaluate factors that correlate with postoperative complications in older patients undergoing surgery for colon cancer. PATIENTS AND METHODS: The database of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) from years 2005 to 2008 was accessed. Patients age 65 and older were included according to Current Procedural Terminology and International Classification of Disease-9 codes. Preoperative and operative variables were examined and postoperative complications assessed using a combination of univariate and multivariate statistical models. Propensity score matching was used to control for nonrandomization of the database. RESULTS: We found that patients undergoing laparoscopic (n = 2113) and open (n = 3801) surgery for the diagnosis of colon cancer were similar in age and gender. However, patients undergoing laparoscopic surgery were generally at lower risk for developing postoperative complications (16.1% vs. 25.4%, P < 0.005). Statistical models controlling for preoperative and operative variables demonstrated patients with elevated body mass index (odds ratio [OR] = 1.26), a history of chronic obstructive pulmonary disease (OR = 1.63), over age 85 (OR = 1.35), a surgery lasting longer than 4 hours (OR = 1.48), or having undergone an open operation (OR = 1.53) to have increased risk for developing postoperative complications. Propensity score match analysis confirmed these results. CONCLUSIONS: Identification of preoperative factors that predispose patients to postoperative complications could allow for the institution of protocols that may decrease these events. Furthermore, expanding the role of laparoscopy in the treatment of older patients with colon cancer may decrease rates of postoperative complications.

Laparoscopy improves short-term outcomes after surgery for diverticular disease.

BACKGROUND & AIMS: Observational studies and small randomized controlled trials have shown that the use of laparoscopy in colon resection for diverticular disease is feasible and results in fewer complications. We analyzed data from a large, prospectively maintained, multicenter database (National Surgical Quality Initiative Program) to determine whether the use of laparoscopy in the elective treatment of diverticular disease decreases rates of complications compared with open surgery, independent of preoperative comorbid factors. METHODS: The analysis included data from 6970 patients who underwent elective surgeries for diverticular disease from 2005 to 2008. Patients with diverticular disease were identified by International Classification of Diseases, 9th revision codes and then categorized into open or laparoscopic groups based on Current Procedural Terminology codes. Preoperative, intraoperative, and postoperative data were analyzed to determine factors associated with increased risk for postoperative complications. RESULTS: Data were analyzed from 3468 patients who underwent open surgery and 3502 patients who underwent laparoscopic procedures. After correcting for probability of morbidity, American Society of Anesthesiology class, and ostomy creation, overall complications (including superficial surgical site infections, deep incisional surgical site infections, sepsis, and septic shock) occurred with significantly lower incidence among patients who underwent laparoscopic procedures compared with those who received open operations. CONCLUSIONS: The use of laparoscopy for treating diverticular disease, in the absence of absolute contraindications, results in fewer postoperative complications compared with open surgery.

Small bowel obstruction following restorative proctocolectomy: affected by a laparoscopic approach?

BACKGROUND: Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the gold standard surgical treatment for chronic ulcerative colitis. More recently, this procedure is being performed laparoscopically assisted. Postoperatively, small bowel obstruction (SBO) is one of the more common associated complications. However, it is unknown whether the addition of a laparoscopic approach has changed this risk. This study aims to assess and compare the incidence of SBOs after both open and laparoscopic restorative proctocolectomy. METHODS: All subjects who underwent restorative proctocolectomy from 1998-2008 were identified from a prospective Colorectal Surgery Database. Medical records were reviewed for all cases of SBO, confirmed by a combination of clinical symptoms and radiologic evidence. Comparisons were made between laparoscopic and open approaches. The incidence of SBO was also subdivided into pre-ileostomy takedown, early post-ileostomy takedown (30 d post), and late post-ileostomy takedown (30 d to 1 y post). Several potential risk factors were also evaluated. Statistical analysis was performed utilizing Fisher's exact (for incidence) or t-tests (for means). Significance was defined as P < 0.05 RESULTS: A total of 290 open cases and 100 laparoscopic cases were identified during this time period. The overall incidence of SBO at 1 y post-ileostomy takedown was 14% (n = 42) in the open group and 16% (n = 16) laparoscopic (P = NS). In the pre-ileostomy takedown period the incidence of SBO was 7% (n = 21) open and 13% (n = 13) laparoscopic (P = NS). While in the post-takedown period, the early incidence was 4% (n = 12) open and 1% (n = 1) laparoscopic and late incidence was 3% (n = 9) open and 2% (n = 2) laparoscopic (P = NS). Factors associated with an increased risk of SBO include coronary artery disease, prior appendectomy and W and J pouch configurations. CONCLUSIONS: The burden of postoperative small bowel obstruction after restorative proctocolectomy is not changed with a laparoscopic approach. Most cases occur in the early postoperative period, especially prior to ileostomy reversal.

The Optimal Ileal Pouch: Physiologic Parameters Significantly Correlate with Overall Pouch Function.

BACKGROUND: Ileal pouch function is affected by several patient factors and pouch physiology. The significance of pouch physiology on optimal pouch function has not been well characterized. The purpose of this study was to examine specific post-ileal pouch anal anastomosis (IPAA) physiologic parameters to determine impact on pouch function and quality of life. METHODS: Patients undergoing proctocolectomy with IPAA for ulcerative colitis were examined. Post-IPAA compliance, pouch anal pressure gradient (PAPG), and function were assessed 6-8 months postoperatively. Compliance was calculated as change in volume divided by change in pressure. PAPG was calculated as the difference between anal pressure and intra-pouch pressure at a fixed volume. Pouch function evaluation included stool frequency and episodes of incontinence. Quality of life was evaluated using the Rockwood Fecal Incontinence Quality of Life Scale. RESULTS: A total of 125 patients were investigated. Post-IPAA resting anal pressure averaged 58.1 ± 15 mmHg. Mean volume and intra-pouch pressure at evacuation were 245 mL and 33.9 mmHg, respectively. Compliance averaged 11.2 mmHg/mL with a mean PAPG of - 29.3 mmHg. Compliance and PAPG correlated with 24-h (p = 0.003, p = 0.004) and nighttime stool frequency (p = 0.04, p = 0.03). Daytime continence was impacted by compliance (p = 0.04), PAPG (p = 0.02), and resting anal pressure (p = 0.02). CONCLUSION: This unique evaluation reveals a significant correlation between IPAA physiologic properties and function. Optimal function and quality of life depend in part on maintaining optimal pouch compliance and pressure differentials between the pouch and anal canal, defined by the pouch anal pressure gradient.

Body mass index does not affect postoperative morbidity and oncologic outcomes of total mesorectal excision for rectal adenocarcinoma.

INTRODUCTION: Obesity adds to the technical difficulty of colorectal surgery and is a risk factor for postoperative complications. We hypothesized that obese patients have increased morbidity and poor oncologic outcomes after proctectomy for rectal adenocarcinoma. METHODS: Adult patients undergoing total mesorectal excision (TME) for rectal adenocarcinoma at a tertiary referral center were retrospectively identified from a prospectively maintained database. Operative characteristics, postoperative complication rates, and oncologic outcomes were compared in patients with BMI > or = 30 kg/m(2) and BMI < 30 kg/m(2). RESULTS: Between 1997 and 2009, 254 patients underwent proctectomy for rectal adenocarcinoma, of whom 27% were obese. There were no significant differences in demographics, comorbidities or preoperative oncologic characteristics between obese and nonobese groups. Patients with BMI > or = 30 kg/m(2) had longer operative times (p = 0.04) and higher intraoperative blood loss (p < 0.001) but comparable postoperative complication rates (p = 0.80), number of lymph nodes retrieved (p = 0.57), margin-negative resections (p = 0.44), and disease-free survival (p = 0.11). Obese patients had longer overall survival (p = 0.05). Tumor stage was the only variable associated with disease-free (p < 0.001) and overall survival (p < 0.001). CONCLUSION: Despite increased technical difficulty of resection, obesity does not increase the risk of postoperative morbidity or adversely affect oncologic outcomes after total mesorectal excision of rectal adenocarcinoma.

Large-Field-of-View Visualization with Small Blind Spots Utilizing Tilted Micro-Camera Array for Laparoscopic Surgery.

Existing laparoscopic surgery systems use a single laparoscope to visualize the surgical area with a limited field of view (FoV), necessitating maneuvering the laparoscope to search a target region. In some cases, the laparoscope needs to be moved from one surgical port to another one to detect target organs. These maneuvers would cause longer surgical time and degrade the efficiency of operation. We hypothesize that if an array of cameras can be deployed to provide a stitched video with an expanded FoV and small blind spots, the time required to perform multiple tasks at different sites can be significantly reduced. We developed a micro-camera array that can enlarge the FoV and reduce blind spots between the cameras by optimizing the angle of cameras. The video stream of this micro-camera array was designed to be processed in real-time to provide a stitched video with the expanded FoV. We mounted this micro-camera array to a Fundamentals of Laparoscopic Surgery (FLS) laparoscopic trainer box and designed an experiment to validate the hypothesis above. Surgeons, residents, and a medical student were recruited to perform a modified bean drop task, and the completion time was compared against that measured using a traditional single-camera laparoscope. It was observed that utilizing the micro-camera array, the completion time of the modified bean drop task was 203 ± 55 s while using the laparoscope, the completion time was 245 ± 114 s, with a p-value of 0.00097. It is also observed that the benefit of using an FoV-expanded camera array does not diminish for subjects who are more experienced. This test provides convincing evidence and validates the hypothesis that expanded FoV with small blind spots can reduce the operation time for laparoscopic surgical tasks.

Attenuated Salmonella typhimurium-mediated interleukin-10 delivery is beneficial for dextran sodium sulfate-induced murine colitis.

PURPOSE: Interleukin-10 is a potent immunoregulatory agent that appears to play a role in inflammatory bowel disease. We hypothesized that interleukin-10 delivery to the distal gastrointestinal tract using a unique delivery vehicle may serve as a novel therapeutic for the treatment of experimental colitis. METHODS: A murine interleukin-10 cDNA was subcloned and transformed into attenuated Salmonella typhimurium. In vitro interleukin-10 production and biofunction were evaluated. This construct was then used against dextran sodium sulfate-induced murine colitis. RESULTS: A murine interleukin-10 producing S. typhimurium model was constructed. Enzyme linked immunosorbent assay and mast cell bioassay revealed interleukin-10 production. After single oral gavage feeding of 10 bacteria, persistence was noted within mesenteric lymph nodes at 6 weeks. Inoculation with/without the interleukin-10 plasmid (n = 7 per group) was performed before and after dextran sodium sulfate exposure. Postdextran sodium sulfate treatment revealed enhanced weight recovery in the S. typhimurium/interleukin-10 group compared to S. typhimurium/plasmid and phosphate buffered saline controls (P < 0.0001). The mean histology score for S. typhimurium/interleukin-10 was 0.86 compared to 3.14 and 3.17 for the S. typhimurium/plasmid and phosphate buffered saline controls respectively (P = 0.028). CONCLUSIONS: Attenuated S. typhimurium producing interleukin-10 can be successfully delivered to the murine gastrointestinal tract by single oral dosing. This novel delivery method improved recovery of chemically-induced murine colitis.

Laparoscopic restorative proctocolectomy with ileal S-pouch.

PURPOSE: Restorative proctocolectomy has revolutionized the surgical management of ulcerative colitis and familial polyposis syndromes. Though now evolved to include laparoscopy, this approach has not included alternative pouch designs such as ileal S-pouch reconstruction. This comparative analysis evaluated the combination of laparoscopic-assisted total proctocolectomy with an ileal S-pouch design. METHODS: One hundred fifty-six (65 laparoscopic-assisted) total proctocolectomy and ileal S-pouch-anal anastomosis procedures performed between 2003 to 2007 were identified from a prospective surgical database. Operative time, length of incision, length of hospital stay, complications, and return of bowel function were examined. A cost analysis including preoperative through postoperative hospital stay and operating room and postanesthesia care unit costs was performed. RESULTS: The laparoscopic-assisted total proctocolectomy and ileal S-pouch-anal anastomosis procedures were performed for ulcerative colitis in 60 cases and familial adenomatous polyposis in the remaining 5 patients. Four conversions to open technique occurred (6 percent). Comparing laparoscopic and open procedures, the laparoscopic approach took longer to perform than the open technique (mean 451 minutes vs. 347 minutes open; P < 0.001). The mean hospital stay was 6.3 days in the laparoscopic group vs. 8.2 days in the open group (P < 0.001). A detailed cost analysis revealed similar overall costs between the laparoscopic ($18,700) and open approaches ($18,500). CONCLUSION: Use of a laparoscopic total proctocolectomy with ileal S-pouch-anal anastomosis reconstruction minimizes incision size and shortens hospital stay. At a teaching academic institution, the laparoscopic approach requires longer operative times yet a negligible cost disadvantage.

Laparoscopic and minimally invasive resection of malignant colorectal disease.

Minimally invasive surgery for colorectal cancer is a burgeoning field of general surgery. Randomized controlled trials have assessed short-term patient-oriented and long-term oncologic outcomes for laparoscopic resection. These trials have demonstrated that the laparoscopic approach is equivalent to open surgery with a shorter hospital stay. Laparoscopic resection also may result in improved short-term patient-oriented outcomes and equivalent oncologic resections versus the open approach. Transanal excision of select rectal cancer using endoscopic microsurgery is promising and robotic-assisted laparoscopic surgery is an emerging modality. The efficacy of minimally invasive treatment for rectal cancer compared with conventional approaches will be clarified further in randomized controlled trials.

A tertiary care hospital's 10 years' experience with rectal ultrasound in early rectal cancer.

BACKGROUND AND OBJECTIVES: Rectal endoscopic ultrasound (RUS) has become an essential tool in the management of rectal adenocarcinoma because of the ability to accurately stage lesions. The aim of this study was to identify the staging agreement of early RUS-staged rectal adenocarcinoma with surgical resected pathology and ultimately determine how this impacts the management of early rectal cancer (T1-T2). METHODS: Retrospective chart review was performed from November 2002 to November 2013 to identify procedure indication, RUS staging data, surgical management, and postoperative surgical pathology data. RESULTS: There were a total of 693 RUS examinations available for review and 282 of these were performed for a new diagnosis of rectal adenocarcinoma. There was staging agreement between RUS and surgical pathology in 19 out of 20 (95%) RUS-staged T1 cases. There was staging agreement between RUS and surgical pathology in 3 out of 9 (33%) RUS-staged T2 cases. There was significantly better staging agreement for RUS-staged T1 lesions compared to RUS staged T2 lesions (P = 0.002). Nearly 60% of T1N0 cancers were referred for transanal excisions (TAEs), and 78% of T2N0 cancers underwent low anterior resection. CONCLUSIONS: This study identified only a small number of T1-T2 adenocarcinomas. There was good staging agreement between RUS and surgical pathology among RUS-staged T1 lesions whereas poor staging agreement among RUS-staged T2 lesions. Although TAE is largely indicated by the staging of a T1 lesion, this approach may be less appropriate for T2 lesions due to high reported local recurrence.

Large-Field-of-View Visualization Utilizing Multiple Miniaturized Cameras for Laparoscopic Surgery.

The quality and the extent of intra-abdominal visualization are critical to a laparoscopic procedure. Currently, a single laparoscope is inserted into one of the laparoscopic ports to provide intra-abdominal visualization. The extent of this field of view (FoV) is rather restricted and may limit efficiency and the range of operations. Here we report a trocar-camera assembly (TCA) that promises a large FoV, and improved efficiency and range of operations. A video stitching program processes video data from multiple miniature cameras and combines these videos in real-time. This stitched video is then displayed on an operating monitor with a much larger FoV than that of a single camera. In addition, we successfully performed a standard and a modified bean drop task, without any distortion, in a simulator box by using the TCA and taking advantage of its FoV which is larger than that of the current laparoscopic cameras. We successfully demonstrated its improved efficiency and range of operations. The TCA frees up a surgical port and potentially eliminates the need of physical maneuvering of the laparoscopic camera, operated by an assistant.

A 30-year analysis of colorectal adenocarcinoma in transplant recipients and proposal for altered screening.

PURPOSE: The risk of malignancy after solid-organ transplantation is well documented. However, the incidence and specific risk for colorectal adenocarcinoma, although previously proposed, has been difficult to calculate. We reviewed the University of Wisconsin transplant database for all cases of colorectal adenocarcinoma to assess the risk of this malignancy, as well as the need for improved screening in this population. METHODS: The transplant database was queried using diagnosis codes for colorectal adenocarcinoma to configure a list of eligible patients. Exclusion criteria included: age less than 18 years at the time of transplant, diagnosis of colorectal cancer or patient death less than 12 months posttransplant, and pretransplant history of colorectal cancer or proctocolectomy. Statistical analysis determined overall incidence, age-specific incidence, and survival for this population. RESULTS: A total of 5,603 kidney, liver, or combination transplants were eligible for analysis from 1966 through 2004. The mean follow-up was 9.3 years. We identified 40 cases of colorectal adenocarcinoma. Twenty-five of these cases (62%) occurred in kidney transplant recipients, 13 after liver transplant, and two after kidney-pancreas combination. Twenty-seven patients (68%) diagnosed with cancer have died, 12 of metastatic disease. The median survival postcancer diagnosis was 2.3 years. These results were compared to the National Cancer Institute Survival, Epidemiology, and End Results (SEER) database for colon and rectal cancer. The current age-adjusted annual incidence based on year 2000 census data is 0.053% (52.9/100,000), and the extrapolated 10-year incidence is 0.27%. The 10-year incidence in the transplanted cohort is 0.71% (incidence ratio = 2.6). The 5-year survival postcancer diagnosis is 63.5% in the general population (SEER), vs. 30.7% in the transplant cohort. The SEER median age at diagnosis of colorectal adenocarcinoma is 72.0 years. Of the transplant recipients who developed cancer, the median age at diagnosis was 58.7 years (32.4 to 78.2), and 11 patients (27%) were diagnosed at or before age 50. In the U.S. population, the annual incidence of colorectal adenocarcinoma below the age of 50 is 0.0055% (5.52/100,000) and the 10-year extrapolated incidence is 0.11%. The 10-year incidence in the under-50 transplant cohort is 0.33% (incidence ratio = 3.0). In this under-50 cohort, median time from transplant to cancer diagnosis was 7.8 years. CONCLUSION: The incidence of and 5-year survival after diagnosis of colorectal adenocarcinoma in transplant recipients is markedly different than the general population. Patients are often diagnosed at a younger age. With current screening guidelines, over 25% of at-risk patients would not be screened. We propose modifying these guidelines to allow earlier detection of colorectal cancer in this population.

Evaluation of submucosal lesions of the large intestine: part 1. Neoplasms.

At luminal evaluation of the large intestine, any masslike protrusion that is covered by normal mucosa, whether the underlying process is intramural or extramural in origin, may be reported as a submucosal lesion. The full characterization of submucosal lesions may be difficult with optical colonoscopy alone, and endoscopic biopsy is often nondiagnostic. Cross-sectional radiologic imaging studies allow evaluation of the entire thickness of the bowel wall and surrounding tissues and often provide additional information with regard to lesion origin, internal composition, and extent of disease. Likewise, it may be difficult to distinguish submucosal lesions from mucosal polyps on radiologic images, and optical colonoscopy may provide complementary information about superficial submucosal soft-tissue lesions that are detected at computed tomographic (CT) colonography or barium imaging. Depending on the specific clinical situation, colonoscopy, CT colonography, transrectal ultrasonography, and magnetic resonance imaging all may play an important role in the diagnostic evaluation of submucosal lesions of the large intestine. It is important that radiologists be familiar with the multimodality imaging appearances of such entities so that neoplasms--especially those that are malignant--can be accurately identified and characterized and effectively managed.