Keep Them on the Table: Outcomes Are Improved After Minimally Invasive Colectomy Despite Longer Operative Times in Patients With High-Risk Colon Cancer.

BACKGROUND: For high-risk patients, traditional surgical dogma advises open operations, with short operative times, to "get them off the table" instead of longer minimally invasive surgery approaches. OBJECTIVE: The aim of this study was to compare postoperative outcomes in patients with high-risk colon cancer undergoing elective longer minimally invasive surgery operations compared with shorter open operations. DESIGN: Retrospective comparative cohort study. SETTINGS: Interventions were performed in hospitals participating in the national surgical database. PATIENTS: The National Surgical Quality Improvement Program database was used to identify patients with colon cancer with ASA class 3 to 4 undergoing right and sigmoid colectomy between 2012 and 2017. MAIN OUTCOME MEASURES: Thirty-day postoperative outcomes were compared between short open and long minimally invasive groups. RESULTS: A total of 3775 patients were identified as having undergone long minimally invasive right colectomy and short open right colectomy (33% open, 67% minimally invasive surgery), and 1042 patients were identified as having undergone long minimally invasive sigmoid colectomy and short open sigmoid colectomy (36% open, 64% minimally invasive). Patients undergoing long minimally invasive right colectomy had significantly lower rates of overall morbidity, severe adverse events, mortality, superficial surgical site infections, and wound disruptions, as well as discharge to a higher level of care and shorter length of stay ( p < 0.05). Patients undergoing long minimally invasive sigmoid colectomy had decreased rates of overall morbidity, severe adverse events, and length of stay, as well as discharge to a higher level of care compared with the patients undergoing short open sigmoid colectomy ( p < 0.05). LIMITATIONS: This study was limited by the retrospective nature and standardized outcome measures. CONCLUSIONS: In high-risk patients undergoing colectomy for colon cancer, outcomes were worse with shorter open compared with longer minimally invasive surgery operations. Focus should shift from getting patients "off the table" faster to longer, but safer, minimally invasive surgery in high-risk patients. See Video Abstract at http://links.lww.com/DCR/B642 . MANTNGALOS SOBRE LA MESA HAY MEJORES RESULTADOS DESPUS DE COLECTOMA MNIMAMENTE INVASIVA A PESAR DE TIEMPOS QUIRRGICOS MS PROLONGADOS EN PACIENTES CON CNCER DE COLON DE ALTO RIESGO: ANTECEDENTES:Para los pacientes de alto riesgo, el dogma quirúrgico tradicional aconseja operaciones abiertas, con tiempos quirúrgicos cortos, con el fin de "sacarlos de la mesa" en lugar de enfoques quirúrgicos mínimamente invasivos más prolongados.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios en pacientes electivos de cáncer de colon de alto riesgo sometidos a operaciones de cirugía mínimamente invasiva más prolongadas en comparación con operaciones abiertas más cortas.DISEÑO:Los resultados posoperatorios de pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha o sigmoidea se compararon en un análisis multivariado. Se comparó el grupo de colectomía derecha abierta corta (tiempo operatorio <116 minutos) y colectomía derecha mínimamente invasiva larga (tiempo operatorio> 132 minutos). También se compararon la colectomía sigmoidea abierta corta (tiempo operatorio <127 minutos) y la colectomía sigmoidea mínimamente invasiva larga (tiempo operatorio> 161 minutos).ESCENARIO:Las intervenciones se realizaron en hospitales participantes en la base de datos quirúrgica nacional.PACIENTES:La base de datos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica se utilizó para identificar a los pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha y sigmoidea entre 2012-2017.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados posoperatorios a los treinta días entre el grupo de procedimientos abiertos cortos y el de mínimamente invasivos largos.RESULTADOS:Se identificó un total de 3.775 pacientes sometidos a colectomía derecha mínimamente invasiva larga y colectomía derecha abierta corta (33% abierta, 67% cirugía mínimamente invasiva) y se identificaron 1042 pacientes sometidos a colectomía sigmoidea mínimamente invasiva larga y colectomía sigmoidea abierta corta (36% abierta, 64% mínimamente invasiva). Los pacientes con colectomía derecha larga mínimamente invasiva tuvieron significativamente menor morbilidad general, eventos adversos graves, mortalidad, infecciones superficiales del sitio quirúrgico, dehiscencia de herida, alta a un nivel más alto de atención y estadía más corta ( p <0.05). Los pacientes con colectomía sigmoidea mínimamente invasiva prolongada tuvieron menor morbilidad general, eventos adversos graves, duración de la estadía y alta a un nivel más alto de atención en comparación con los pacientes con colectomía sigmoidea abierta corta ( p <0.05).LIMITACIONES:Este estudio estuvo limitado por la naturaleza retrospectiva y las medidas de resultado estandarizadas.CONCLUSIONES:En los pacientes de alto riesgo sometidos a colectomía por cáncer de colon, los resultados fueron peores con operaciones abiertas más cortas en comparación con operaciones mínimamente invasivas más largas. El enfoque debe pasar de hacer que los pacientes "salgan rápido de la mesa quirúrgica" a una cirugía mínimamente invasiva más prolongada pero más segura, en pacientes de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B642 . (Traducción-Dr. Jorge Silva Velazco ).

A New Bibliometric Index: The Top 100 Most Disruptive and Developmental Publications in Colorectal Surgery Journals.

BACKGROUND: A new bibliometric index called the disruption score was recently proposed to identify innovative and paradigm-changing publications. OBJECTIVE: The goal was to apply the disruption score to the colorectal surgery literature to provide the community with a repository of important research articles. DESIGN: This study is a bibliometric analysis. SETTINGS: The 100 most disruptive and developmental publications in Diseases of the Colon & Rectum, Colorectal Disease, International Journal of Colorectal Disease, and Techniques in Coloproctology were identified from a validated data set of disruption scores and linked with the iCite National Institutes of Health tool to obtain citation counts. MAIN OUTCOME MEASURES: The primary outcomes measured were the disruption score and citation count. RESULTS: We identified 12,127 articles published in Diseases of the Colon & Rectum (n = 8109), International Journal of Colorectal Disease (n = 1912), Colorectal Disease (n = 1751), and Techniques in Coloproctology (n = 355) between 1954 and 2014. Diseases of the Colon & Rectum had the most articles in the top 100 most disruptive and developmental lists. The disruptive articles were in the top 1% of the disruption score distribution in PubMed and were cited between 1 and 671 times. Being highly cited was weakly correlated with high disruption scores (r = 0.09). Developmental articles had disruption scores that were more strongly correlated with citation count (r = 0.18). LIMITATIONS: This study is subject to the limitations of bibliometric indices, which change over time. DISCUSSION: The disruption score identified insightful and paradigm-changing studies in colorectal surgery. These studies include a wide range of topics and consistently identified editorials and case reports/case series as important research. This bibliometric analysis provides colorectal surgeons with a unique archive of research that can often be overlooked but that may have scholarly significance. See Video Abstract at http://links.lww.com/DCR/B639.UN NUEVO INDICE BIBLIOMÉTRICO: LAS 100 MAS IMPORTANTES PUBLICACIONES EN INNOVACIONES DESESTABILIZADORAS Y DE DESARROLLO EN LAS REVISTAS DE CIRUGÍA COLORRECTALANTECEDENTES:Un nuevo índice bibliométrico llamado innovación desestabilizadora y de desarrollo ha sido propuesto para identificar publicaciones de vanguardia y que pueden romper paradigmas.OBJETIVO:La meta fué aplicar el índice de desestabilización a la literature en cirugía colorectal para aportar a la comunidad con un acervo importante de artículos de investigación.DISEÑO:Un análisis bibliométrico.PARAMETROS:Las 100 publicaciones mas desestabilizadores y de desarrollo en las revistas: Diseases of the Colon and Rectum, Colorectal Disease, International Journal of Colorectal Disease, y Techniques in Coloproctology se recuperaron de una base de datos validada con puntuaciones de desestabilización y se ligaron con la herramienta iCite NIH para obtener la cuantificación de citas.PRINCIPAL MEDIDA DE RESULTADO:El índice desestabilizador y la cuantificación de citas.RESULTADOS:Se identificaron 12,127 articulos publicados en Diseases of the Colon and Rectum (n = 8,109), International Journal of Colorectal Disease (n = 1,912), Colorectal Disease (n = 1,751), y Techniques in Coloproctology (n = 355) de 1954-2014. Diseases of the Colon and Rectum representó la mayoría de las publicaciones dentro de la lista de los 100 mas desestabilizadores y de desarrollo. Esta literatura desestabilizadora se encuentra en el principal 1% de la distribución de la puntuacón desestabilizadora en PubMed y se citaron de 1 a 671 veces. El ser citado con frecuencia se relacionó vagamente con las puntuaciones de desastibilización (r = 0.09). Los artículos de desarrollo tuvieron puntuaciones de desestabilización que estuvieron muy correlacionados con la cuantificación de las citas (r = 0.18).LIMITACIONES:Las sujetas a las limitaciones de los índices bibliométricos, que se modifican en el tiempo.DISCUSION:La putuación de desestabilicación identificó trabajos perspicaces, pragmáticos y modificadores de paradigmas en cirugía colorrectal. Es de interés identificar que se incluyeron una gran variedad de temas y en forma consistente editoriales, reportes de casos y series de casos que representaron una investigación importante. Este análisis bibliométrico aporta a los cirujanos colorrectales de un acervo de investigación único que puede con frecuencia pasarse por alto, y sin embargo tener una gran importancia académica. Consulte Video Resumen en http://links.lww.com/DCR/B639. (Traducción- Dr. Miguel Esquivel-Herrera).

Surgical Residents' Perspective on Informed Consent-How Does It Compare With Attending Surgeons?

BACKGROUND: The informed consent discussion (ICD) is a compulsory element of clinical practice. Surgical residents are often tasked with obtaining informed consent, but formal instruction is not included in standard curricula. This study aims to examine attitudes of surgeons and residents concerning ICD. MATERIALS AND METHODS: A survey regarding ICD was administered to residents and attending surgeons at an academic medical center with an Accreditation Council for Graduate Medical Education-accredited general surgery residency. RESULTS: In total, 44 of 64 (68.75%) residents and 37 of 50 (72%) attending surgeons participated. Most residents felt comfortable consenting for elective (93%) and emergent (82%) cases, but attending surgeons were less comfortable with resident-led ICD (51% elective, 73% emergent). Resident comfort increased with postgraduate year (PGY) (PGY1 = 39%, PGY5 = 85%). A majority of participants (80% attending surgeons, 73% residents) believed resident ICD skills should be formally evaluated, and most residents in PGY1 (61%) requested formal instruction. High percentages of residents (86%) and attendings (100%) believed that ICD skills were best learned from direct observation of attending surgeons. CONCLUSIONS: Resident comfort with ICD increases as residents advance through training. Residents acknowledge the importance of their participation in this process, and in particular, junior residents believe formal instruction is important. Attending surgeons are not universally comfortable with resident-led ICDs, particularly for elective surgeries. Efforts for improving ICD education including direct observation between attending surgeons and residents and formal evaluation may benefit the residency curriculum.

I want to go home: should we abandon open surgery for treatment of rectal prolapse? Consideration of discharge destination following surgery for rectal prolapse.

AIM: Despite the financial and value-based implications associated with higher levels of care at discharge, few studies have evaluated modifiable treatment factors that may optimize postacute care. The aim of this work was to assess the association between operative approach and disposition to a higher level of care and other outcomes following surgery for rectal prolapse. METHOD: Using a retrospective cohort study design, the database of the National Surgical Quality Improvement Program was used to identify patients with rectal prolapse who underwent perineal repair or open or laparoscopic rectopexy with or without resection between 2012 and 2017. Discharge destination and 30-day postoperative outcomes were compared using propensity score mathcing and weighting. Nomograms generated using multivariable regression calculated the risk of requiring higher levels of care upon discharge and morbidity. RESULTS: Propensity-score analysis included 3000 patients [1500 in the perineal group, 580 in the open abdominal group and 920 in the minimally invasive (MIS) group]. Patients who received open abdominal surgery were more likely to require elevation of care at destination compared with those who received perineal surgery (OR 1.65, 95% CI 1.22-1.24) and MIS abdominal surgery (OR 1.80, 95% CI 1.18-2.76). Similar effects were seen for overall morbidity. Increased age, higher American Society of Anesthesiologists class, congestive heart failure, dependent functional status and open surgery were independent predictors of discharge to higher level of care (c-statistic = 0.79). CONCLUSION: Open surgery compared with MIS and perineal surgery was associated with higher levels of discharge disposition following rectal prolapse surgery. Future research should continue to identify modifiable treatment factors that reduce poor postoperative outcomes among patients with rectal prolapse.

Early feeding in colorectal surgery patients: safe and cost effective.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways has demonstrated improved outcomes in colorectal surgery. An important component of ERAS is early oral intake. The aim of this study is to determine the impact of early oral intake in patients following colorectal surgery. METHODS: A retrospective analysis of patients who underwent colectomy and proctectomy at an academic institution from January 2015 to November 2018 was performed. Postoperative outcomes were compared between patients who had postoperative day 0 (POD 0) oral intake and those who did not. RESULTS: A total of 436 ERAS patients had oral intake timing documented. The majority of patients were women (241, 55.3%) and white (313, 71.8%). The mean age was 57 ± 15.09. Patients who had early intake were found to have lower 30-day overall morbidity and length of stay (p < 0.05), and no difference in serious adverse events. Additionally, hospital costs were lower in the POD 0 feeding group for all patients (p < 0.05). CONCLUSION: We have demonstrated that early oral feeding in an established ERAS pathway is associated with improved clinical outcomes as well as decreased total hospital costs. Early postoperative feeding is safe in colorectal patients and should be prioritized to decrease complications and healthcare costs.

A national analysis of operative treatment of adult patients with Hirschsprung's disease.

PURPOSE: Hirschsprung's disease is primarily a disease of infancy, but in rare cases, adults with this condition require surgery. The aim of this study is to identify the types of operations and postoperative outcomes in adults with Hirschsprung's disease on a national level. METHODS: The National Surgical Quality Improvement Program database was used to perform a retrospective review of all adult patients diagnosed with Hirschsprung's disease. Patients were divided into two groups depending on the type of operation: restoration of bowel continuity or diversion of fecal stream; clinicopathologic data and 30-day outcomes were compared between the two groups. RESULTS: A total of 32 patients were analyzed. Fourteen patients (43.8%) underwent diversion and 18 (56.2%) underwent restorative procedures. The median age was 49.5 years old for the diversion group and 23.5 years old for the reconstructive group (p = 0.001). The restorative surgery group was more likely to have an ASA 1-2 while the diversion group had a higher frequency of ASA 3-5 (p = 0.011). The median length of stay for the diversion surgery was 9.5 days and 5 days for the restoration group (p = 0.045). Complications occurred in 57% of patients in the diversion group and in 22% of patients in the restoration group (p = 0.049). There were otherwise no statistically significant differences in intraoperative data and postoperative complications. CONCLUSION: This is the first study using a national database to evaluate the surgical treatment of Hirschsprung's disease in adult patients. Complications are common and were more frequent in the older, sicker diversion group, with restoration of continuity being better tolerated in the younger, healthier patient population.

Are our publications failing the inspection?: a review of the publications in rectal cancer surgery between 2002 and 2012.

BACKGROUND: Quality of publications is considered a subjective measurement, and more weight is placed on prospective studies, especially randomized clinical trials and meta-analyses. OBJECTIVE: This study describes the type of publications and evaluates the quality of randomized clinical trials and review articles using an objective measurement. DATA SOURCES: Medline (PubMed) is the data source for this work. STUDY SELECTION: We used the terms "rectal neoplasms/surgery" and the filters "10 years," "humans," and "English." MAIN OUTCOME MEASURES: We measured compliance with checklist items. Randomized clinical trials were reviewed using the Consolidates Standards of Reporting Trials statement; systematic reviews/meta-analyses were reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: A total of 3603 articles were identified: 20.8% were case report/series, 20.5% were retrospective cohorts, 14.0% were reviews or meta-analyses, 16.4% were prospective cohorts, 14.0% were other types of articles (comments, letters, or editorials), 5.5% were clinical trials (phase I/II), 4.2% were randomized clinical trials, and 4.4% were cross-sectional studies. We reviewed 108 randomized clinical trials; the maximum score possible was 74.0, the average score was 44.6 (range, 20.0-64.0), 4 (3.7%) were graded as "excellent," 21 (19.4%) were "good," 44 (40.7%) were "deficient," and 39 (36.1%) were graded as "fail." The predictors of higher scores for randomized clinical trials were year of publication after 2007 (p = 0.00), higher impact factor (p = 0.03), and declared funding (p = 0.01). Twenty-nine meta-analyses were reviewed; the average score was 19.64 (range, 12.0-25.0); 5 articles (17.2%) were graded as "excellent," 12 (41.4%) were "good," 10 (34.5%) were "deficient," and 2 (6.9%) were "fail." LIMITATIONS: Only 1 electronic database was used, so we lacked a validated score. In addition, the search terms did not include "colorectal." CONCLUSIONS: A total of 20.8% of the articles published were case reports and 25.0% of the articles were prospective or clinical trials. Although randomized clinical trials and systematic reviews provide the highest level of evidence, publications with missing data limit replication of the study and affect the generalizability of results to other populations. To improve the quality of our publications, authors, reviewers, and journal editors should consider the endorsement of standardize checklists.

Tumor scatter after neoadjuvant therapy for rectal cancer: are we dealing with an invisible margin?

BACKGROUND: After the impressive response of rectal cancers to neoadjuvant therapy, it seems reasonable to ask: can we can excise the small ulcer locally or avoid a radical resection if there is no gross residual tumor? Does gross response reflect what happens to tumor cells microscopically after radiation? OBJECTIVE: The aim of this study was to identify microscopic tumor cell response to radiation. DESIGN: This study is a retrospective review of a prospectively collected database. SETTING: This investigation was conducted at a single tertiary medical center. PATIENTS: Patients were selected who had elective radical resection for rectal cancer after preoperative chemotherapy and radiation performed by 2 colorectal surgeons between 2006 and 2011. MAIN OUTCOME MEASURES: The primary outcome measured was tumor presence after radiation therapy RESULTS: Of the 75 patients, 20 patients were complete responders and 55 had residual cancer. Of these patients, 28 had no tumor cells seen outside the gross ulcer, and 27 (49.1%) had tumor outside the visible ulcer or microscopic tumor present with no overlying ulcer. Of these tumors, 81.5% were skewed away from the ulcer center. The mean distance of distal scatter was 1.0 cm from the visible ulcer edge to a maximum of 3 cm; 3 patients had tumor cells more than 2 cm distal to the visible ulcer edge. Tumor scatter outside the ulcer was not associated with poor prognostic factors, such as nodal and distant disease, perineural invasion, or mucin; however, it was associated with lymphovascular invasion (χ2 = 4.12, p = 0.038) LIMITATIONS: There was limited access to clinical information gathered outside our institution. CONCLUSIONS: Our study suggests that 1) after radiation, the gross ulcer cannot be used to determine the sole area of potential residual tumor, 2) cancer cells may be found up to 3 cm distally from the gross ulcer, so the traditional 2-cm margin may not be adequate, and 3) local excision of the ulcer or no excision after apparent complete response appears to be insufficient treatment for rectal cancer.

It Takes a Village: The First 100 Patients Seen in a Multidisciplinary Pelvic Floor Clinic.

OBJECTIVE: This study aimed to assess the characteristics of patients assessed and treated at a multidisciplinary pelvic floor program that includes representatives from multiple specialties. Our goal is to describe the process from triaging patients to the actual collaborative delivery of care. This study examines the factors contributing to the success of our multidisciplinary clinic as evidenced by its ongoing viability. METHODS: This is a descriptive study retrospectively analyzing a prospectively maintained database that included the first 100 patients seen in the Program for Abdominal and Pelvic Health clinic between December 2017 and October 2018. We examined patient demographics, their concerns, and care plan including diagnostic tests, findings, treatments, referrals, and return visits. RESULTS: The clinic met twice monthly, and the first 100 patients were seen over the course of 10 months. The most common primary symptoms were pelvic pain (45), constipation (30), bladder incontinence (27), bowel incontinence (23), high tone pelvic floor dysfunction (23), and abdominal pain (23); most patients had more than one presenting symptom (76). The most common specialties seen at the first visit to the clinic included gastroenterology (56%), followed by physical medicine and rehabilitation (45%), physical therapy (31%), female pelvic medicine and reconstructive surgery (25%), behavioral health (19%), urology (18%), and colorectal surgery (13%). Eleven patients were entirely new to our hospital system. Most patients had diagnostic tests ordered and performed. CONCLUSIONS: A multidisciplinary clinic for abdominal and pelvic health proves a sustainable model for comprehensive treatment for patients with pelvic floor dysfunction, including difficulties with defecation, urination, sexual dysfunction, and pain.

Morbidity and mortality in octogenarians and older undergoing major intestinal surgery.

PURPOSE: The elderly constitute an increasing portion of the world's population. Our study assessed morbidity, mortality, and outcome in octogenarians who have undergone lower intestinal operations, and compared outcome between subsequent decades. METHODS: A total of 138 octogenarians who underwent 157 operations were retrospectively studied (1995-2005). The American Society of Anesthesiologists Physical Status classification, blood loss, length of surgery, surgical intensive care unit admission, length of surgical intensive care unit and hospital stay, and complications were recorded. Emergency vs. elective and cancer vs. noncancer cases were compared. Results were compared for the years 1985 to 1994. RESULTS: Cancer comprised 63 percent of cases. The most common causes of mortality were sepsis and multiorgan failure. Differences (P < 0.05) were found for elective vs. emergent surgeries according to age, length of stay, complications, surgical intensive care unit admission, American Society of Anesthesiologists Physical Status classification, and mortality. Noncancer cases were more likely to be emergent, have a higher American Society of Anesthesiologists Physical Status classification, and a higher mortality rate. When emergency operations were excluded, there were no significant differences between cancer vs. noncancer cases. In a comparison of two decades (1985-1994 vs. 1995-2005), we found that the mortality rate in patients younger than aged 85 years decreased by more than 10 percent (P < 0.05). Patients older than aged 85 years demonstrated no significant differences between decades. The strongest determinants of outcome are emergency status and the presence of comorbid conditions. CONCLUSIONS: Elective surgery in the elderly is safe. Emergency surgery is accompanied by significant morbidity and mortality.

Morbidity and mortality of the Confederate generals during the American Civil War.

During the American Civil War (1861-1865), 426 men were commissioned generals by Jefferson Davis and the Confederate Congress. Eighty (19%) died of battle wounds (versus 8% in the Union army) and 3 per cent died of disease. During the war, 211 (49%) were wounded; of these, each was wounded a mean 1.9 times. When noncombatants are excluded, 52 per cent sustained wounds. Of those who served in five or more major engagements, 62 per cent were wounded; of those who fought in more than 10, 71 per cent sustained wounds. Sixty-five per cent of battlefield deaths were immediate and 85 per cent were from gunshot wounds. Mortality did not vary by state of birth, age group, rank (brigadier, major, lieutenant, full), formal military education, or prewar profession. Professional soldiers fared no better or worse than prewar civilians appointed to the rank of general. Of those who survived the war, mean age at death was 68.0 years.

Laparoscopic rectopexy without resection: a worthwhile treatment for rectal prolapse in patients without prior constipation.

Anterior resection with rectopexy is considered by many to be the best operation for rectal prolapse. It is feared that if sigmoid redundancy created by rectal mobilization is not resected, colonic motility (specifically constipation) could be disabling. We contend that resection is not necessary in patients without preexisting constipation. We tested this hypothesis using a laparoscopic approach to minimize hospital stay. Twelve patients were treated (eight women); mean age was 45 years (range, 25-82 years). No patient had preexisting constipation; one had irritable bowel syndrome. Three patients had prior prolapse operations. Full rectal mobilization was undertaken down to the levator hiatus; neither the mesenteric vessels nor the lateral ligaments were divided. Rectopexy to the presacral fascia was done with one to two Nurolon sutures on either side of the rectum. There were no complications; mean hospital stay was 4 days. Mean follow up was 32 months (range; 3-75 months); there have been no recurrences. Only the patient with irritable bowel syndrome developed significant constipation. We conclude: 1) rectopexy can be safely done laparoscopically, 2) resection is not required in the absence of prior constipation, and 3) rectal mobilization and rectopexy does not predispose to future constipation in these selected patients.

Hartmann's colostomy reversal: outcome of patients undergoing surgery with the intention of eliminating fecal diversion.

Reversal of a Hartmann's operation can be a morbid undertaking; successful restoration of intestinal continuity cannot be guaranteed. Between June 2001 and July 2006, 35 Hartmann's reversals were undertaken. There were 19 males (54%). Mean age was 54.7 years (range, 14-82 years). Twenty-one (60%) patients had their Hartmann's for diverticular disease, 7 (20%) for anorectal cancer, 4 (11%) for volvulus, and 3 for miscellaneous reasons. Mean length of stay was 7.7 days (range, 3-16 days); 23 per cent required intensive care for a mean 2.3 days (range, 1-4 days). Blood loss was 470 mL, and mean operative time was 4.28 hours (range, 1-8.3 hours). The mean time interval between the original operation and its reversal was 8.9 months (range, 1.4-55 months). Extensive lysis of adhesions was required in 69 per cent, 40 per cent experienced minor complications (urinary tract infections, ileus, and so on), and 38 per cent had major complications (myocardial infarction, leak, hernias, respiratory failure). There was one death (3%). The operation failed because of intraoperative circumstances in three patients (8%). Ten patients (26%) had stomas at the time of discharge of which 3 were intended to be permanent and 7 were temporary. Of the latter, 3 were successfully closed, 3 are awaiting closure, and 1 had complete anastomotic failure requiring permanent diversion. Total failure rate was 10.3 per cent; contributing factors included prior radiation and ultra-low anastomoses.

Patient factors may predict anastomotic complications after rectal cancer surgery: Anastomotic complications in rectal cancer.

PURPOSE: Anastomotic complications following rectal cancer surgery occur with varying frequency. Preoperative radiation, BMI, and low anastomoses have been implicated as predictors in previous studies, but their definitive role is still under review. The objective of our study was to identify patient and operative factors that may be predictive of anastomotic complications. METHODS: A retrospective review was performed on patients who had sphincter-preservation surgery performed for rectal cancer at a tertiary medical center between 2005 and 2011. RESULTS: 123 patients were included in this study, mean age was 59 (26-86), 58% were male. There were 33 complications in 32 patients (27%). Stenosis was the most frequent complication (24 of 33). 11 patients required mechanical dilatation, and 4 had operative revision of the anastomosis. Leak or pelvic abscess were present in 9 patients (7.3%); 4 were explored, 2 were drained and 3 were managed conservatively. 4 patients had permanent colostomy created due to anastomotic complications. Laparoscopy approach, BMI, age, smoking and tumor distance from anal verge were not significantly associated with anastomotic complications. After a multivariate analysis chemoradiation was significantly associated with overall anastomotic complications (Wall = 0.35, p = 0.05), and hemoglobin levels were associated with anastomotic leak (Wald = 4.09, p = 0.04). CONCLUSION: Our study identifies preoperative anemia as possible risk factor for anastomotic leak and neoadjuvant chemoradiation may lead to increased risk of complications overall. Further prospective studies will help to elucidate these findings as well as identify amenable factors that may decrease risk of anastomotic complications after rectal cancer surgery.

Rectovaginal fistula.

Rectovaginal fistulas present a distressing problem for the patient and a challenge for the treating physician. Successful management must take into consideration the etiology of the fistula and the health of both the rectum and the patient. Obstetrical fistulas can be treated successfully by local approaches transanally or transvaginally. Episioproctotomy may be considered if there is an associated sphincter defect. Crohn's related fistulas usually require proctectomy if the rectum is severely involved. Local repair can be considered in instances where the rectum is relatively healthy and local sepsis has been controlled. Radiation-induced fistulas may be secondary to cancer recurrence, which must be excluded. If the patient is not a candidate for a radical resectional approach, fecal diversion alone should be performed.

Anorectal anatomy and embryology.

The anal canal is complex in its anatomy and its embryologic origin. The intricate and changing histology of the anal canal explains the different types of anal cancer. In addition, an understanding of the venous and the lymphatic drainage of the anal canal helps to explain its methods of dissemination. Finally, the basis for the treatment of anal cancer is derived from the cancer's anatomic origins.

In situ mesh repair of parastomal hernias.

Options for the repair of parastomal hernias include contralateral transposition or in situ repair. The latter can be accomplished either primarily or with prosthetic mesh. Concerns with mesh include possible gut erosion and infection. Recurrence rates in the literature are dismal regardless of technique. We retrospectively reviewed our experience with this problem focusing on in situ repairs. We identified 9 patients who underwent 10 in situ repairs. Of these, 6 were women, average age was 69.4 years, and stomas had been constructed for cancer in 6, inflammatory bowel disease in 2, and incontinence in 1. Eight patients had colostomies; one had an ileostomy. All patients were symptomatic from their hernias. Repairs were performed an average of 8 years after stoma construction. Hernia repair was performed transabdominally in four and through a parastomal incision in six. Complications included hematoma formation requiring evacuation in one and delayed resumption of oral intake secondary to nausea and cramps in three. Of the 9 initial repairs, 1 recurred (11%) and was repaired without subsequent failure. No mesh erosions or wound infections have occurred. This technique is safe and may be preferable to contralateral placement of the stoma.

Anal complications after restorative proctocolectomy (J-pouch).

A prospective assessment was performed to determine the incidence of anal complications after ileoanal J-pouch anastomosis procedures for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). From 1989 to 2000, 75 patients (50 male and 25 female) underwent proctocolectomy and ileal pouch-anal anastomosis with temporary loop ileostomy for UC (N = 68) and FAP (N = 7). Overall 33 patients (44%) developed anal complications postoperatively. Nineteen patients (25%) had mild anal stenosis amenable to digital dilatation in the office. Ten patients (13%) had severe anal stenosis requiring operative dilatation. Ileostomy closure was delayed longer than 3 months in four patients because of anal stenosis. One patient never had his ileostomy closed secondary to severe anal stenosis. Anal fissures developed in one patient that resolved with conservative treatment. Three patients developed fistula-in-ano and one patient developed a pouch-vaginal fistula. Of these four patients two later manifested signs of Crohn's disease. Four patients developed perirectal abscesses (three without fistulas) that were treated with incision and drainage. Two patients had presacral (anastomotic) abscesses; one patient was treated with temporary anastomotic diversion and the other underwent a permanent ileostomy and pouch resection. Both of these patients were later diagnosed with Crohn's disease. Anal complications developed in 17 of 41 (41%) handsewn anastomoses, 16 of 34 (47%) stapled anastomoses, three of seven (43%) patients with FAP, and 30 of 68 (44%) patients with UC. Operative technique and disease type did not significantly correlate with the type of anal complication. However, hand-sewn anastomoses had a higher incidence of severe strictures and FAP patients did not develop anal abscesses, fistulas, or fissures. Forty-five per cent of our patients with abscesses/fistulas and all of our patients with presacral abscesses from anastomotic dehiscence were later diagnosed with Crohn's disease. Anal complications after ileoanal J-pouch anastomosis are relatively common.