Correlation of Tumor Response Between Flexible Sigmoidoscopy and Magnetic Resonance Imaging in Patients Undergoing Neoadjuvant Therapy for Locally Advanced Rectal Cancer: A Retrospective Review.

BACKGROUND: The National Accreditation Program for Rectal Cancer recommends a pelvic MRI to assess the response to neoadjuvant therapy for advanced rectal cancers. However, there is no single restaging modality that can identify all patients with complete tumor response. At our institution, we perform both a pelvic MRI and a flexible sigmoidoscopy (FS) after neoadjuvant therapy prior to surgical resection. OBJECTIVE: The objective is to elucidate the correlation of tumor response between FS and MRI in patients undergoing neoadjuvant therapy for locally advanced rectal cancer. DESIGN: Single institution from 2010 to 2019. Retrospective cohort study comparing local tumor response on FS to MRI utilizing final pathology as the gold standard for comparison. PATIENTS: Patients with confirmed locally advanced rectal adenocarcinoma (stage II or III) who underwent neoadjuvant therapy prior to surgical intervention and underwent flexible endoscopy and a standardized rectal cancer protocol MRI to evaluate tumor response. RESULTS: A total of 48 patients were evaluated. Seven (14%) patients had a complete pathological response. MRI adequately reported 1 (14%), while FS found 4 (57.14%) out of the 7 complete responders. Nevertheless, this did not reach statistical significance (P = .06). On logistic regression analysis, flexible sigmoidoscopy had a 5.5 higher likelihood to report an accurate complete response (OR 5.5, 95% CI: 1.02-29.64; P = .047). CONCLUSIONS: Flexible sigmoidoscopy should be used in conjunction with MRI in the work up of patients who have received neoadjuvant therapy for advanced rectal cancer prior to surgical resection.

Use of Botulinum Toxin Injections for the Treatment of Chronic Anal Fissure: Results From an American Society of Colon and Rectal Surgeons Survey.

BACKGROUND: Chronic anal fissure (CAF) is commonly treated by colorectal surgeons. Pharmacological treatment is considered first-line therapy. An alternative treatment modality is chemical sphincterotomy with injection of botulinum toxin (BT). However, there is a lack of a consensus on the BT administration procedure among colorectal surgeons. METHODS: A national survey approved by the American Society of Colon and Rectal Surgeons (ASCRS) Executive Council was sent to all members. An eight-question survey was sent via ASCRS email correspondence between December 2019 and February 2020. Questions were derived from available meta-analyses and expert opinions on BT use in CAF patients and included topics such as BT dose, injection technique, and concomitant therapies. The survey was voluntary and anonymous, and all ASCRS members were eligible to complete it. Responses were recorded and analyzed via an online survey platform. RESULTS: 216 ASCRS members responded to the survey and 90% inject 50-100U of BT. Most procedures are performed under MAC anesthesia (56%). A majority of respondents (64%) inject into the internal sphincter and a majority (53%) inject into 4 quadrants in the anal canal circumference. Some respondents perform concomitant manual dilatation (34%) or fissurectomy (38%). Concomitant topical muscle relaxing agents are not used uniformly among respondents. DISCUSSION: Injection of BT for CAF is used commonly by colorectal surgeons. There is consensus on BT dosage, administration site, technique, and the use of monitored anesthesia care.

Feasibility assessment of outpatient colorectal resections at a tertiary referral center.

PURPOSE: Enhanced Recovery After Surgery (ERAS) protocols, particularly when paired with advanced laparoscopy, have reduced recovery time following colorectal procedures. The aim of this study was to determine if length of stay (LOS) could be reduced to an overnight observation stay (< 24 h) with comparable perioperative morbidity. The secondary aim was to establish predictive factors contributing to early discharge. METHODS: This is a retrospective cohort study of all colectomies at a tertiary care center between January 2016 and January 2019. Inclusion criteria included all colorectal resections with varying surgical approaches. Patients underwent a standardized ERAS protocol. A logistical regression model was conducted for predictive factors. RESULTS: Three hundred sixty patients were included (55.3% female). Of these, 78 (21.7%) patients were discharged within < 24 h and 112 (31.1%) were discharged within 24-48 h. The remainder comprised the > 48 h group. Age differed significantly between the < 24 h and 24-48 h groups (p < 0.0001). Patients discharged within 24 h were younger (59.4 ± 12.3 years), had a lower CCI score (3.1; p = 0.0026), and lower ASA class (p < 0.0001). Emergency department visits (p = 0.3329) and readmissions (p = 0.6453) prior to POD 30 remained comparable among all groups. Younger age, low ASA, and minimally invasive surgical approach all contributed to ultra-fast discharge. CONCLUSION: ERAS protocols may allow for discharge within 24 h following a major colorectal resection, all with low perioperative morbidity and mortality. The predictive factors for discharge within 24 h include a low ASA (I or II), and a minimally invasive surgical approach.

Enhanced Recovery After Surgery Protocols. Does Frailty Play a Role?

INTRODUCTION: The 5-modified frailty index (mFI) is a valid predictor of 30-day mortality after surgery. With the wide implementation of enhanced recovery after surgery (ERAS) protocols in colorectal patients, the predictive power of frailty and its contribution to morbidity and length of stay (LOS) can be underestimated. METHODS: We reviewed all colectomy patients undergoing ERAS protocol at a single, tertiary care institution from January 2016-January 2019. The 5-mFI score was calculated based on the presence of 5 comorbidities: Congestive heart failure (CHF), diabetes mellitus, chronic obstructive pulmonary disease, functional status, and hypertension (HTN). Multivariate analysis was used to assess the impact of 5-mFI score on morbidity, emergency department (ED) visits, readmissions, and LOS. RESULTS: 360 patients were evaluated including 163 elderly patients. Frailer patients had a higher rate of ED visits (P = .024), readmissions (P = .029), and LOS (P < .001). Patients with CHF had a higher chance of prolonged LOS, whereas patients with HTN had a higher chance of ED. Elderly patients with an mFI score of 3 and 4 were likely to have longer LOS (P = .01, P = .07, respectively). Elderly patients with an mFI score of 4 were 15 times more likely to visit ED and 22 times more likely to be readmitted than patients with an mFI score of 0. DISCUSSION: An increase in 5-mFI for elderly patients undergoing colorectal procedures increases ED visits or readmissions, and it correlates to a higher LOS, especially in elderly patients. This instrument should be used in the assessment of frail, elderly patients undergoing colorectal procedures.

Protocol-Based Intravenous Fluid Hydration for Newly Created Ileostomies Decreases Readmissions Secondary to Dehydration.

BACKGROUND: Newly created ileostomies often result in patient readmission due to dehydration secondary to high ostomy output. Implementation of a mandatory home intravenous hydration protocol can avoid this. We aim to evaluate the impact of mandatory home intravenous hydration for patients with newly created ileostomies. MATERIALS AND METHODS: All patients at a single, tertiary care center who underwent ileostomy creation during a period of sporadic home intravenous hydration (February 2011-December 2013) and mandatory protocol hydration (March 2016-December 2018) were reviewed for incidence of dehydration, readmissions, and emergency department visits. RESULTS: 241 patients were evaluated. 119 were in the "sporadic" group and 122 were in the "protocol" group. Operative approach differed among both groups, with hydration protocol patients undergoing 15% less open procedures and 4.9% more hand-assisted laparoscopic procedures (P = .0017). Prior to protocol implementation, 23.5% of patients were sent home with intravenous hydration. Length of hospital stay after index ileostomy creation was shorter for "protocol" patients by 3.3 days (P < .0001). 15.1% of "sporadic" patients experienced dehydration as compared to 7.4% of "protocol" patients (P = .0283). Following protocol implementation, the number of patients readmitted due to dehydration increased from 13 to 14 (P = .01). DISCUSSION: Standardized, mandatory at-home intravenous hydration following ileostomy creation leads to a significant reduction in postoperative incidence of dehydration and dehydration-associated readmissions. This protocol should be followed for all patients with newly created ileostomies, so long as adequate home health nursing support and active surveillance are available.

Rectal Cancer Complete Response Outcomes in a Community-Based Hospital Comparable with Large Cancer Centers When Multidisciplinary Approach to Rectal Cancer Is Used.

Achievement of pathologic complete response (pCR) in patients with locally advanced rectal cancer correlates with improved prognosis relative to non-pCR counterparts. Such correlations are not well established in the context of a community-based hospital. This study aims to examine pCR rates, recurrences, and survival data for locally advanced rectal cancer patients in community settings. A single-center retrospective chart review was performed at a community-based hospital. Study population consisted of 119 patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy, followed by surgical resection. Patients with a history of metastasis, inflammatory bowel disease, hereditary cancer syndromes, concurrent or prior malignancy, and emergent surgery were excluded. Twenty-four patients (20.2%) achieved pCR. Across both groups, all demographics and perioperative characteristics were comparable. The five-year survival was 73.7 per cent in the non-pCR group and 95.8 per cent in the pCR group (P = 0.0243). At five years, 27.7 per cent of the non-pCR group had a recurrence, as compared with none in the pCR group (P = 0.0018). Based on our study, we believe that a multidisciplinary approach to rectal cancer used at a community-based hospital can achieve oncological outcomes and survival benefits similar to those of larger academic tertiary care institutions.

S128: Active post discharge surveillance program as a part of Enhanced Recovery After Surgery protocol decreases emergency department visits and readmissions in colorectal patients.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs aim to standardize perioperative care to reduce morbidity and cost. Our study examined an Active Post-Discharge Surveillance (APDS) program in reducing avoidable readmissions and emergency department (ED) visits in postoperative colorectal ERAS patients. METHODS: Colectomy (right, subtotal and total) and low anterior resection cases performed at a tertiary care hospital between 2015 and 2018 were reviewed. ED visits, 30-day readmissions, and patients' APDS participation were assessed. Our APDS followed a modern text messaging paradigm offered to all patients free-of-charge. RESULTS: Of 236 patients that underwent colectomy, 123 utilized APDS and 113 did not. Overall, both non-surveillance (NS) and active surveillance (AS) groups had similar preoperative characteristics. Length of hospital stay at index surgery was longer in the NS compared to AS group, 4.7 ± 2.6 vs. 2.6 ± 2.8 days, respectively (p < 0.001). In the NS group, 16 patients visited the ED, of which 14 (14/16, 87.5%) were ultimately readmitted. One patient was directly readmitted from the surgeon's office, resulting in a total of 15 (15/113, 13.3%) total patients readmitted by postoperative day (POD) 30. In the AS group, 9 patients visited the ED, of which 7 (7/9, 77.8%) were ultimately readmitted. One patient was directly readmitted, resulting in a total of 8 (8/123, 6.5%) total patients readmitted by POD 30. AS patients had significantly lower odds of visiting the ED when compared to NS patients (OR: 0.356; 95% CI: 0.138-0.919; p = 0.0328). Similarly, AS patients had significantly lower odds of readmission when compared to NS patients (OR: 0.343; 95% CI: 0.132-0.892; p = 0.0283). CONCLUSIONS: APDS allows many postoperative issues to be resolved in outpatient settings without ER visits or readmission. This indicates APDS is a valuable ERAS adjunct by establishing a cost-effective and convenient communication line between patients and their surgical team.

Findings on Colonoscopy after Diverticulitis: A Multicenter Review.

Diverticular disease is a common problem where patients with diverticulosis have a 1-4 per cent risk of acute diverticulitis. Current guidelines recommend a colonoscopy after.the resolution of acute diverticulitis. The aim of this study was to evaluate the yield of significant findings on colonoscopy after an episode of diverticulitis. This is a retrospective analysis of patients who underwent colonoscopy after an episode of diverticulitis between November 2005 and August 2017 at three major teaching hospitals. Advanced adenomas were defined as adenomas ≥1 cm, serrated adenomas, and tubulovillous or villous adenomas. A total of 584 patients (298 males; 51%) underwent colonoscopy for a history of diverticulitis after resolution of acute symptoms. Colonoscopy was complete in 488 patients (84%). Among these 488 patients, 446 had diverticular disease, 31 had advanced adenomas, and four had adenocarcinomas. Colonoscopies were incomplete in 96 patients (16%). Forty-six of those patients underwent surgery. The overall incidence of advanced adenomas and adenocarcinomas was 32 (5.4%) and nine (1.5%), respectively. In our study, the prevalence of advanced adenomas and adenocarcinomas was relatively high compared with the average risk individuals. Our findings support that patients after an episode of diverticulitis should continue to get a colonoscopy.

Wide local excision of perianal Paget's disease with gluteal flap reconstruction: an interdisciplinary approach.

Perianal Paget's disease (PPD) is an extremely rare condition characterized as intraepithelial adenocarcinoma of unclear etiology. It can be either primary or secondary. The disease typically presents as an eczema-like, erythematous, and painful skin lesion that is associated with pruritus. It is usually misdiagnosed as a common anorectal problem. Surgical excision is the preferred treatment of PPD, with the specific technique being dependent upon disease invasiveness. The treatment may involve reconstructive surgery. A 61-year-old female with a history of rectal pain and intermittent pruritus for the past two years presented with large painful lesions in her perianal area including the anal verge, diagnosed as primary PPD. After excluding other malignancies elsewhere, a laparoscopic ileostomy followed by a wide local excision (WLE) of the PPD was performed by a colorectal team. Reconstruction of the defect with gluteal advancement flaps was performed by the plastic surgeon. The patient recovered uneventfully. Her surgical site showed healing without flap compromise, widely open anal opening, and full sphincter control at the three-month follow-up exam. The patient returned to normal function after ileostomy closure. WLE with bilateral V-Y gluteal flap advancement is a feasible treatment for primary PPD.