Early-Onset Colorectal Cancer in Patients under 50 Years of Age: Demographics, Disease Characteristics, and Survival.

INTRODUCTION: Incidence of early-onset colorectal cancer (EO-CRC) is increasing in younger demographics. This study analyzes disease-specific survival in individuals under 50 years of age. METHODS: Patients with colorectal malignancy were identified in the Surveillance Epidemiology and End Results (SEER) database from 2004 to 2015. Cases were categorized into typically screened (age 50-79 years) and non-typically screened (age 20-49 years) cohorts, as well as by decade. Kaplan-Meier curves and Cox proportional hazard models were used to study survival. RESULTS: A total of 240,772 patients with colorectal cancer were analyzed. Average annual percent change in incidence was -0.24% among typically screened patients and +1.12% among patients with EO-CRC. Patients with EO-CRC more frequently presented with distal tumors (70.6% vs. 57.6%, P < .001) and advanced tumor stage (61.3% vs. 48.6%, P < .001). Patients aged 50 and over had comparable 5 year disease-specific survival to younger patients (68.2% vs. 66.4%, P = .31); however, patients in the 3rd, 4th, and 8th decade of life had particularly low survival rates (59.0% vs. 65.8% vs. 65.8%, logrank P < .001). Patients aged 20-29 years had the most increased risk of cause-specific mortality on univariable Cox regression analysis [HR 1.43, 95% CI 1.31-1.56; P < .001], although this was not significant on multivariable analysis [HR 1.06, 95% CI 0.97-1.15; P = .201]. Male sex, older age, advanced stage, rectal and/or cecal primary, and earlier year of diagnosis were independently associated with increased mortality. CONCLUSION: Patients with EO-CRC are diagnosed at a later stage and have lower disease-specific survival than those in typically screened cohorts. Additional studies on tumor biology and surveillance strategies are needed to improve outcomes in this population.

Does Rectocele Repair Combined with Other Perineal Surgeries Affect Outcome Compared to Solo Rectocele Repair?

OBJECTIVES: Rectocele is common in female patients. To date, there is no literature comparing outcomes of rectocele repairs in combination with other perineal surgeries. We aim to analyze perioperative morbidity and mortality as well as long-term outcome of rectocele repair in combination with other perineal surgeries (RR combination) and compare this with solo rectocele repair (solo RR). DESIGN: The type of study was case-control. Data of patients who received solo rectocele repair or rectocele repair in combination with other perineal surgeries between January 2011 and December 2015 were identified and reviewed in a prospectively maintained and IRB-approved database. Ninety-eight patients were included, including 41 patients in the solo RR group and 57 patients in the RR combination group. The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were observed. METHODS: The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were compared, respectively. Covariate adjustment was analyzed by multivariate logistic and Cox regression analysis. RESULTS: Ninety-eight patients with a median age of 57 were included, involving 41 patients in the solo RR group and 57 patients in the RR combination group. Other than the operative approach (p < 0.01), demographics and preoperative characteristics of the 2 groups were comparable. All variables, including length of stay, estimated blood loss, self-limiting rectal bleeding, transfusion, urinary retention, rectal stricture, rectal and perineal infection, rectovaginal abscess, reoperation, effective resolution of obstructive defecation symptoms, residual symptoms rate, and recurrence rate, were comparable among the 2 groups except for operative time (p = 0.03). LIMITATIONS: This study is a single-center study, which may cause bias. In addition, the sample size is limited. Staging of rectocele and routine imaging studies were not performed. CONCLUSIONS: Rectocele repair in combination with other perineal surgeries is feasible, and outcomes are comparable with solo rectocele repair. Transanal versus transvaginal repairs appear to have no influence on outcomes.

Intraoperative Colonoscopy During Colorectal Surgery Does Not Increase Postoperative Complications: An Assessment From the ACS-NSQIP Procedure-targeted Cohort.

Intraoperative colonoscopy (IOC) is an adjunct in colorectal surgery to detect the location of the lesions and assessing anastomotic integrity. The authors aimed to evaluate the safety and feasibility and postoperative morbidity of IOC in left-sided colectomy patients for colorectal cancer. Patients undergoing elective left-sided colectomy without any proximal diversion for colorectal cancer between 2013 and 2016 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted database. Demographics, comorbidities, short-term outcomes, and postoperative morbidity of patients were evaluated. A total of 8811 patients were identified and IOC was performed for 1143 (12.97%) patients. There was no significant difference in postoperative complications between the IOC and non-IOC groups. Patients with IOC had shorter total hospital length of stay. The use of IOC does not adversely affect short-term outcomes after colorectal resections. Surgeons may utilize IOC liberally for left-sided colorectal resections.

Investigation of the enhanced recovery after surgery protocol outcome on post colectomy patients.

BACKGROUND: An enhanced recovery after surgery (ERAS) protocol was implemented to improve quality and cost effectiveness of surgical care in elective colorectal procedures. METHODS: A retrospective study was conducted from July 2017 to June 2018. The ERAS protocol was initiated on 9 July 2018 and retrospectively reviewed in July 2019 by chart review, the American College of Surgeons National Surgical Quality Improvement Project database and risk stratification using Clavien-Dindo classification for all elective colorectal procedures. RESULTS: A total of 109 patients, 55 (pre-ERAS) and 54 (post-ERAS) are included in the final analysis. There were no differences in complications were recorded (p = 0.37) and 30-day readmissions (p = 0.785). The mean hospital stay was 5.89 ± 2.62 days in pre-ERAS and 4.94 ± 2.27 days in post-ERAS group which was statistically significant (p = 0.047). CONCLUSIONS: An ERAS protocol for colorectal surgery harmonised perioperative care and decreased length of stay.

Perineal stapled rectal resection without a contour transtar: a modified approach.

Perineal stapled prolapse resection is a novel approach for treating rectal prolapse in elderly and frail patients. This study aimed to report a modified technique using only a straight linear stapler. A 94-year-old female with 15-cm full thickness rectal prolapse was treated using a linear cutter in the left and right lateral quadrants, and then resection was completed by using the same instrument in the anterior and posterior flaps. The procedure was performed under local anesthesia and in a prone jackknife position. There was no morbidity or mortality, and the patient was discharged on postoperative day 2. Follow-up at 9 months revealed no recurrent prolapse, and the patient was asymptomatic. This technique is easy, safe, and fast to perform without using contour transtar (Ethicon Endo-Surgery, Cincinnati, OH).

Impact of omentoplasty on anastomotic leak and septic complications after low pelvic anastomosis: a study from the NSQIP database.

PURPOSE: The role of omentoplasty in the prevention of anastomotic leak (AL) in colorectal surgery is controversial. The aim of this study was to evaluate the impact of omentoplasty on AL and septic complications after low pelvic anastomosis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS: The ACS-NSQIP database was queried for patients who underwent segmental colectomy with low pelvic anastomosis by using 2012 targeted colectomy participant use data file. Patients were divided into two groups according to omentoplasty versus no-omentoplasty formation. AL and surgical site infections (SSIs) within postoperative 30 days were compared between the groups. RESULTS: A total of 2891 patients (1447 [50.1%] males) with a mean age of 60.2 ± 13.0 years met the inclusion criteria. There were 86 (2.9%) and 2805 (97.1%) patients in the omentoplasty and no-omentoplasty group, respectively. In the multivariate analysis, omentoplasty neither reduced AL (p = 0.83; OR = 0.88, 95% CI, 0.21-2.44) nor organ/space SSIs (p = 0.08; OR = 2.14, 95% CI, 0.91-4.41). Also, this technique did not play any role in reducing AL and organ/space SSI rates regardless of diversion with the exception of its association with higher organ/space SSIs in patients without diverting stoma (9.2% vs 3.8%, p = 0.04). No differences were detected between the groups with respect to the management strategies for AL (p = 0.22). CONCLUSIONS: Omentoplasty did not decrease AL and septic complications after low pelvic anastomosis and had no impact on the postoperative management of AL.

Comparisons of the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center.

PURPOSE: Intestinal obstruction is a leading cause of patient mortality and the most common reason for emergent operation in colorectal surgery. The influence of inter-hospital transfer on patients' outcomes varies greatly in different diseases. We aimed to compare the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. METHODS: All intestinal obstruction patients operated in Cleveland Clinic from Jan 2012 to Dec 2016 were collected from a prospectively maintained database. Preoperative characteristics; surgical outcomes, including intraoperative complication, postoperative complication, readmission, reoperation, and postoperative 30-day mortality; and medical cost were collected. All parameters were compared between two groups before and after propensity score match. Multivariate logistic analysis was used to explore risk factors of surgical outcomes. RESULTS: A total of 576 patients were included, with 75 in the transferred group and 501 in the directly admitted group. Before match, the transferred patients had longer waiting interval from admission to surgery (p < 0.001), more contaminated or infected wounds (p = 0.02), different surgical procedures (p = 0.02), and similar surgical outcomes and total medical cost (all p > 0.05), compared with the directly admitted group. Multivariate analysis showed that inter-hospital transfer was not an independent predictor of any surgical outcome. After matching to balance the preoperative characteristics between two groups, no significant differences were identified in all surgical outcomes and total medical cost between two groups (all p > 0.05). CONCLUSIONS: Compared with directly admitted patients, transferred intestinal obstruction patients are associated with similar surgical outcomes and similar medical costs.

Colonoscopy-induced acute diverticulitis: myth or reality?

BACKGROUND: Colonoscopy in patients with diverticulosis can be technically challenging and limited data exist relating to the risk of post-colonoscopy diverticulitis. Our aim was to evaluate the incidence, management, and outcomes of acute diverticulitis following colonoscopy. METHODS: Study design is retrospective cohort study. Data were gathered by conducting an automated search of the electronic patient database using current procedural terminology and ICD-9 codes. Patients who underwent a colonoscopy from 2003 to 2012 were reviewed to find patients who developed acute diverticulitis within 30 days after colonoscopy. Patient demographics and colonoscopy-related outcomes were documented, which include interval between colonoscopy and diverticulitis, colonoscopy indication, simultaneous colonoscopic interventions, and follow-up after colonoscopy. RESULTS: From 236,377 colonoscopies performed during the study period, 68 patients (mean age 56 years) developed post-colonoscopy diverticulitis (0.029%; 2.9 per 10,000 colonoscopies). Incomplete colonoscopies were more frequent among patients with a history of previous diverticulitis [n = 10 (29%) vs. n = 3 (9%), p = 0.03]. Mean time to develop diverticulitis after colonoscopy was 12 ± 8 days, and 30 (44%) patients required hospitalization. 34 (50%) patients had a history of diverticulitis prior to colonoscopy. Among those patients, 14 underwent colonoscopy with an indication of surveillance for previous disease. When colonoscopy was performed within 6 weeks of a diverticulitis attack, surgical intervention was required more often when compared with colonoscopies performed after 6 weeks of an acute attack [n = 6 (100%) vs. n = 10 (36%), p = 0.006]. 6 (9%) out of 68 patients received emergency surgical treatment. 15 (24%) out of 62 patients who had non-surgical treatment initially underwent an elective sigmoidectomy at a later date. Recurrent diverticulitis developed in 16 (23%) patients after post-colonoscopy diverticulitis. CONCLUSIONS: Post-colonoscopy diverticulitis is a rare, but potentially serious complication. Although a rare entity, possibility of this complication should be kept in mind in patients presenting with symptoms after colonoscopy.

Factors associated with portomesenteric venous thrombosis after total colectomy with ileorectal anastomosis or end ileostomy.

BACKGROUND: Porto-mesenteric venous thrombosis (PMVT) is an uncommon but serious complication. Data on the risk factors for PMVT following total colectomy with ileorectal anastomosis or end ileostomy (TC/IRA or EI) is limited. This study aimed to evaluate the factors associated with PMVT after TC/IRA or EI. METHODS: Patients who underwent elective TC/IRA or EI between January 2010 and December 2014 were identified from institutional database. Patients who had CT proven PMVT within 30 days of surgery were included in the PMVT positive group. Demographics and perioperative/postoperative 30-day outcomes were compared between groups. RESULTS: Out of 832 patients, 34 patients (4.1%) were diagnosed with PMVT. PMVT positive group were younger (35.8vs.41 years, p = 0.03). Postoperative organ-space surgical site infection (17.6% vs. 4.8%, p = 0.007), deep venous thrombosis (8.8%vs.1.5%, p = 0.02), ileus (38.2%vs.20.8%, p = 0.018), and readmission (50.0%vs.12.7%, p < 0.001) were more common in patients with PMVT, who also had longer hospital stay (8.5vs.6 days, p = 0.002). CONCLUSIONS: PMVT after TC/IRA or EI may occur in non-IBD patients. PMVT should be included in differential diagnosis after TC/IRA or EI in patients with intraabdominal infection or ileus, especially in younger patients.

Does the timing of loop ileostomy closure affect outcome: A case-matched study.

INTRODUCTION: The optimal timing for the closure of loop ileostomies remains controversial. The aim of this study is to determine whether ileostomy closure (<3 months post formation) affects stoma-related morbidity compared to late closure (≥3 months post formation). METHODS: All patients who had loop ileostomy and ileostomy closure between 2012 and 2015 were identified from an IRB-approved, prospectively maintained institutional database.The patients who underwent ileostomy closure (<3 months) were compared against matched patients undergoing ileostomy closure (≥3 months). The outcomes for the two groups were compared. RESULTS: A total of 358 patients were analyzed. Mean age was 46 ± 17 years. There were 179 patients in each group [ileostomy closure (<3 months) and ileostomy closure (≥3 months)]. Both groups were matched. Groups were comparable in preoperative characteristics and demographics. All of the peri-operative variables were comparable. No difference was observed in estimated blood loss (EBL), operative time (OT) and length of stay (LOS) (all p > 0.05). Postoperative outcomes including wound infection, post-operative bleeding, intra-abdominal abscess, ileus, small bowel obstruction (SBO), anastomotic leak, reoperation, surgery related readmission, postoperative transfusion were also similar among the groups (p > 0.05). CONCLUSIONS: Ileostomy closure (<3 months) is practical and safe. It does not increase morbidity and significantly reduces the time patient has a stoma. This may be advantageous in regards to having a reduced possibility of stoma related complications.

Colonic Diverticulosis and Diverticulitis in Renal Transplant Recipients: Management and Long-Term Outcomes.

Data regarding management of colonic diverticulitis in renal transplant recipients (RTRs) are limited. This study aims to identify prevalence, risk factors, and outcomes in RTRs with colonic diverticulosis and diverticulitis. Between January 2004 and December 2013, all patients who underwent kidney transplantation were analyzed. Among all RTSs, patients who had a pretransplant colonoscopic diagnosis of diverticulosis and patients with a proven attack of diverticulitis were included in our analysis. There were 1578 RTRs with a mean age of 50 ± 14 years at the time of transplantation. Of these, 409 patients had colonoscopic evaluation and 174 (43%) were diagnosed with diverticular disease. Fifteen (0.9%) out of 1578 developed a primary attack of diverticulitis. Two patients underwent a Hartmann's procedure due to perforation. Among 13 patients who were initially treated nonoperatively, 4 required surgery due to refractory diverticulitis (n = 2) and recurrence (n = 2). Tobacco use (59% vs 48%, P = 0.02), increased age (58 vs 51 years, P < 0.0001), diabetes (33% vs 35%, P = 0.03), coronary artery disease (38% vs 22%, P = 0.001), and autosomal dominant polycystic kidney disease etiology (P = 0.04) were more common in RTRs with diverticulosis. Majority of RTRs with diverticulitis can be managed nonoperatively. Surgical treatment is warranted in patients with perforated, persistent, and recurrent diverticulitis. A special care and follow-up may be needed in RTRs with autosomal dominant polycystic kidney disease etiology, smoking history, and coronary artery disease due to higher risk of diverticulosis and subsequent potential diverticulitis.

Natural history of bleeding risk in colonic diverticulosis.

Colonic diverticulosis prevalence is gradually increasing worldwide. From 3% to 15% of the patients with diverticulosis will bleed at some point. The risk for rebleeding after the first episode is substantial but varies in the literature between 13-48%. We analyzed risk factors for diverticular bleed and management options for initial and recurrent diverticular bleeding. A review of the literature on this subject is presented.

Risk factors associated with postoperative morbidity in over 500 colovesical fistula patients undergoing colorectal surgery: a retrospective cohort study from ACS-NSQIP database.

PURPOSE: The aim of this study was to evaluate the impact of various factors on 30-day postoperative morbidity in patients who underwent colorectal surgery (CRS) for colovesical fistula (CVF) in the elective and emergency settings. METHODS: Patients who underwent CRS for CVF between 2005 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database by using current procedural terminology codes. Demographics, perioperative, and operative factors were assessed and compared between two groups classified according to the presence or absence of postoperative complications. RESULTS: Five hundred twelve patients met the inclusion criteria [mean age of 61.4 (±14.7) years, female 214 (42%)]. Etiology of fistula was diverticulitis [N = 438 (85.5%)], colon cancer [N = 39 (7.6%)], and Crohn's disease [N = 35 (6.8%)]. One hundred fifty-two procedures (29.7%) were performed laparoscopically. In 186 patients (36%), no bladder intervention was performed. One hundred forty-nine patients (29.1%) had at least one postoperative complication. Patients who developed complication were older (P = <0.001), more often female (P = <0.001), hypertensive (P = 0.005), anemic (P = <0.001), preoperatively transfused (P = 0.02), and with class 2-3 wound classification (P = 0.01). Independent risk factors affecting morbidity were increased age [odds ratio (OR) 1.23 (1.03-1.47), P = 0.01], decreased hematocrit level [OR 3.04(1.83-5.06), P < 0.0001], and open approach [OR 2.56 (1.35-4.84), P = 0.003]. CONCLUSIONS: Morbidity for CVF remains high. Lower preoperative hematocrit level and increased age were associated with higher risk of complication. Laparoscopic surgery may be preferable when possible as morbidity is less with this approach.

Management of colorectal neoplasia during pregnancy and in the postpartum period.

AIM: To report our experience on management of colorectal neoplasia during pregnancy and in the postpartum period. METHODS: Patients who were diagnosed with colorectal cancer during pregnancy or in the postpartum period (< 6 mo), between 8/1997 and 4/2013, in our department were reviewed. Patient characteristics, operations, fetal health and follow-up during pregnancy, type of delivery and oncologic outcomes were analyzed. RESULTS: Eight patients met our study criteria. Median age at the time of diagnosis of colorectal cancer was 31 years. Median follow-up after surgery was 36 mo. Median duration of symptoms before diagnosis was 16 wk. Three patients were diagnosed with colorectal cancer during pregnancy and underwent surgery prior to delivery. None of the patients received adjuvant treatment during pregnancy. Five patients were diagnosed with colorectal cancer within a median of 2.1 mo after delivery and underwent surgery. No adverse neonatal outcomes were noted. All deliveries were at term (2 cesarean sections) except for one preterm delivery following low anterior resection on the 34(th) week of pregnancy. CONCLUSION: There has been a significant delay in the diagnosis of colorectal cancer which is probably due to overlap of symptoms and signs between these tumors and a normal pregnancy. Surgery for colorectal cancer during pregnancy can be performed safely without compromising maternal and fetal outcomes.

Does omental pedicle flap reduce anastomotic leak and septic complications after rectal cancer surgery?

INTRODUCTION: Whether creation of omental pedicle flap (OPF) to reinforce bowel anastomosis can reduce septic outcomes remains controversial. The aim of this study was to investigate the role of this technique on anastomotic leak and septic complications after rectal cancer surgery. METHODS: Patients who underwent rectal cancer surgery from 01/2008 to 12/2013 were identified and categorized into two groups based on OPF creation versus no-OPF creation. Clinical, operative characteristics and postoperative anastomotic leak and surgical site infections within 30 days after surgery were compared between the groups. RESULTS: There were 65 (14%) and 403 (86%) patients in OPF and no-OPF group, respectively. In multivariate analysis, OPF was not found to be associated with anastomotic leak (p = 0.35), organ/space infections (p = 0.99) and overall surgical site infections (p = 0.65). Three hundred and sixty eight (78.6%) patients underwent diversion. OPF did not reduce septic complications irrespective of the stoma status (p > 0.05). There were no differences between the two groups in terms of operative (p = 0.46) and non-operative management (p = 0.14). CONCLUSION: OPF neither reduced the incidence of anastomotic leak and surgical site infections nor had any impact on the management of anastomotic leak.

Impact of Transfusion Threshold on Infectious Complications After Ileal Pouch-Anal Anastomosis.

BACKGROUND: This study was conducted to investigate the impact of different hemoglobin level-based transfusion practices on infectious complications after surgery for ulcerative colitis. METHODS: Patients who underwent ileal pouch-anal anastomosis for ulcerative colitis between January 2008 and December 2013 were identified and divided into four groups: group 1 with hemoglobin ≥ 10 and group 2 with hemoglobin ≥ 7 and <10 g/dL who did not receive transfusion and group 3 with hemoglobin ≥ 7 and <10 and group 4 with hemoglobin < 7 g/dL who received transfusion. Clinical characteristics and septic complications within postoperative 30 days were compared. RESULTS: There were 237, 341, 40, and 20 patients in groups 1, 2, 3, and 4, respectively. All the groups were comparable regarding perioperative characteristics except for age, gender, preoperative albumin and hemoglobin levels, and operative blood loss. The rates of overall septic complications were 18.6, 26.7, 47.5, and 40 % in the groups 1, 2, 3 and 4, respectively. In multivariate analysis, compared to group 2, group 3 was associated with an increased likelihood of developing organ/space (odds ratio (OR) = 4.34, p = 0.004) and overall surgical site infections (SSIs) (OR = 2.81, p = 0.01). CONCLUSION: Blood transfusion decided based on a perioperative hemoglobin (Hgb) level above 7 mg/dL is associated with higher overall and organ/space SSIs.

Mesh herniorrhaphy with simultaneous colorectal surgery: a case-matched study from the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: The aim of this study is to evaluate the impact of concurrent mesh herniorrhaphy on short-term outcomes of colorectal surgery by using a large, nationwide database. METHODS: Patients who underwent simultaneous ventral hernia repair (VHR) and colorectal surgery between 2005 and 2010 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent VHR with mesh repair were case matched with patients who underwent VHR without mesh based on the type of colorectal procedure, diagnosis, and American Society of Anesthesiologists score. RESULTS: Two hundred sixty-two patients who underwent VHR with mesh were case matched with 524 patients who underwent VHR without mesh. Mean operating time was significantly longer in patients who underwent VHR with mesh (195.8 ± 98.7 vs 164.3 ± 84.4 minutes, P < .001). Postoperative morbidity (P = .58), mortality (P = .27), superficial surgical site infection (SSI) (P = .14), deep SSI (P = .38), organ space SSI (P = .17), wound disruption (P > .99), reoperation (P = .48), and length of hospital stay (P = .71) were comparable between the groups. CONCLUSION: The American College of Surgeons National Surgical Quality Improvement Program data suggest that VHR with mesh does not increase 30-day mortality, medical or surgical morbidity in colorectal surgery setting.