Reasons for Long-term Opioid Prescriptions After Guideline-directed Opioid Prescribing and Excess Opioid Pill Disposal.

OBJECTIVES: The aim of this study was to determine the frequency and reasons for long-term opioid prescriptions (rxs) after surgery in the setting of guideline-directed prescribing and a high rate of excess opioid disposal. BACKGROUND: Although previous studies have demonstrated that 5% to 10% of opioid-naïve patients prescribed opioids after surgery will receive long-term (3-12 months after surgery) opioid rxs, little is known about the reasons why long-term opioids are prescribed. METHODS: We studied 221 opioid-naïve surgical patients enrolled in a previously reported prospective clinical trial which used a patient-centric guideline for discharge opioid prescribing and achieved a high rate of excess opioid disposal. Patients were treated on a wide variety of services; 88% of individuals underwent cancer-related surgery. Long-term opioid rxs were identified using a Prescription Drug Monitoring Program search and reasons for rxs and opioid adverse events were ascertained by medical record review. We used a consensus definition for persistent opioid use: opioid rx 3 to 12 months after surgery and >60day supply. RESULTS: 15.3% (34/221) filled an opioid rx 3 to 12 months after surgery, with 5.4% and 12.2% filling an rx 3 to 6 and 6 to 12 months after surgery, respectively. The median opioid rx days supply per patient was 7, interquartile range 5 to 27, range 1 to 447 days. The reasons for long-term opioid rxs were: 51% new painful medical condition, 40% new surgery, 6% related to the index operation; only 1 patient on 1 occasion was given an opioid rx for a nonspecific reason. Five patients (2.3%) developed persistent opioid use, 2 due to pain from recurrent cancer, 2 for new medical conditions, and 1 for a chronic abscess. CONCLUSIONS: In a group of prospectively studied opioid-naïve surgical patients discharged with guideline-directed opioid rxs and who achieved high rates of excess opioid disposal, no patients became persistent opioid users solely as a result of the opioid rx given after their index surgery. Long-term opioid use did occur for other, well-defined, medical or surgical reasons.

Does Long-Term Bowel Function Change After Colectomy for Colon Malignancy?

INTRODUCTION: Current understanding of bowel function after colectomy for colon cancer is informed by conflicting data, making preoperative patient counseling difficult. Our previous work demonstrates bowel movement frequency increases by postoperative follow-up, while overall function does not change. Long-term changes are unknown. We aimed to evaluate changes to patient-reported bowel function after colectomy for colon malignancy. METHODS: This is an observational study of patients that underwent colectomy for colon malignancy and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative and 30-d postoperative clinic visits. Long-term bowel function was assessed using the same questionnaire via telephone or surveillance clinic visit. Mean domain and Total COREFO scores were compared baseline to long-term using paired t-tests. Quality of life analysis was obtained using the Patient Reported Outcome Measurement Information System-10 Global Health questionnaire for patients who completed this measure at surveillance visits or via telephone. RESULTS: Sixty-six patients met inclusion criteria. Median time between baseline and long-term questionnaire completion was 16 mo (interquartile range 11-30). Stool-related aspects (pain and bleeding with bowel movements, anal skin irritation) improved significantly from baseline to long-term. There were no other differences in any domain or Total COREFO score. Patient Reported Outcome Measurement Information System-10 scores demonstrated quality of life equivalent to the general US population. CONCLUSIONS: Over the long-term, after colectomy for colon cancer, patients report improvements in stool-related aspects (pain and bleeding with bowel movements, anal skin irritation). Evidence-based preoperative patient counseling should include these findings.

Reducing New Ileostomy Readmissions in a Rural Health Care Setting: A Quality Improvement Initiative.

BACKGROUND: Readmission after ileostomy creation continues to be a major cause of morbidity with rates ranging from 15% to 30% due to dehydration and obstruction. Rural environments pose an added risk of readmission due to larger travel distances and lack of consistent home health services. OBJECTIVE: This study aimed to reduce ileostomy-related readmission rates in a rural academic medical center. DESIGN: This is a rapid cycle quality improvement study. SETTING: This single-center study was conducted in a rural academic medical center. PATIENTS: Colorectal surgery patients receiving a new ileostomy were included in this study. INTERVENTIONS: Improvement initiatives were identified through Plan-Do-Study-Act cycles (enhanced team continuity, standardized rehydration, nursing/staff education). MAIN OUTCOME MEASURES: Thirty-day readmission, average length of stay, and average time to readmission served as main outcome measures. RESULTS: Roughly equal rates of ileostomy were created in each time point, consistent with a tertiary care colorectal practice. The preimplementation readmission rate was 29%. Over the course of the entire quality improvement initiative, re-admission rates decreased by more than 50% (29% to 14%). PDSA cycle 1, which involved integrating a service-specific physician assistant to the team, allowed for greater continuity of care and had the most dramatic effect, decreasing rates by 27.5% (29% to 21%). Standardization of oral rehydration therapy and the implementation of a patient-directed intake/output sheet during PDSA cycle 2 resulted in further improvement in readmission rates (21% to 15%). Finally, implementation of nurse and physician assistant (PA)-driven patient education on fiber supplementation resulted in an additional yet nominal decrease in readmissions (15% to 14%). Latency to readmission also significantly increased throughout the study period. LIMITATIONS: This study was limited by its small sample size in a single-center study. CONCLUSION: Implementation of initiatives targeting enhanced team continuity, the standardization of rehydration therapies, and improved patient education decreased readmission rates in patients with new ileostomies. Rural centers, where outpatient resources are not as readily available or accessible, stand to benefit the most from these types of targeted interventions to decrease readmission rates. See Video Abstract at http://links.lww.com/DCR/B771. REDUCCIN EN LAS READMISIONES POR ILEOSTOMAS NE MEDIOS DE ATENCIN MDICA RURAL INICIATIVA DE MEJORA EN LA CALIDAD: ANTECEDENTES:La readmisión después de la creación de una ileostomía sigue siendo una de las principales causas de morbilidad con tasas que oscilan entre el 15% y el 30% debido a la deshidratación y la oclusión. Un entorno rurale presenta un riesgo adicional de readmisión debido a las mayores distancias de viaje y la falta de servicios de salud domiciliarios adecuados.OBJETIVO:Reducir las tasas de reingreso por ileostomía en un centro médico académico rural.DISEÑO:Estudio de mejoría de la calidad de ciclo rápido.AJUSTE:Estudio unicéntrico en una unidad de servicio médico académico rural.PACIENTES:Pacientes de cirugía colorrectal a quienes se les confeccionó una ileostomía.INTERVENCIONES:Iniciativas de mejoría identificadas a través de los ciclos Planificar-Hacer-Estudiar-Actuar (Continuidad del equipo mejorada, rehidratación estandarizada, educación de enfermería / personal).PRINCIPALES MEDIDAS DE RESULTADO:30 días de readmisión, duración media de la estadía hospitalaria, tiempo medio de reingreso.RESULTADOS:Se crearon tasas aproximadamente iguales de ileostomías un momento dado de tiempo, subsecuentes en la práctica colorrectal de atención terciaria. La tasa de readmisión previa a la implementación del estudio fue del 29%. En el transcurso de toda la iniciativa de mejoría en la calidad, las tasas de readmisión disminuyeron en más del 50% (29% a 14%). El ciclo 1 de PDSA, que implicó la integración en el equipo de un asistente médico específico, lo que permitió una mayor continuidad en la atención y tuvo el mayor efecto disminuyendo las tasas en un 27,5% (29% a 21%). La estandarización de una terapia de rehidratación oral y la implementación de una hoja de ingresos / perdidas dirigida al paciente durante el ciclo 2 de PDSA resultó en una mejoría adicional en las tasas de readmisión (21% a 15%). Finalmente, la implementación de la educación del paciente impulsada por enfermeras y AF sobre el consumo suplementario de dietas con fibra dio como resultado una disminución adicional, aunque nominal, de las readmisiones (15% a 14%). La latencia hasta la readmisión también aumentó significativamente durante el período de estudio.LIMITACIONES:Estudio de un solo centro con un muestreo de pequeño tamaño.CONCLUSIONES:La implementación de iniciativas dirigidas a mejorar la continuidad en el equipo, la estandarización de las terapias de rehidratación y la mejoría en la información de los pacientes disminuyeron las tasas de readmisión en todos aquellas personas con nuevas ileostomías. Los centros rurales, donde los recursos para pacientes ambulatorios no están tan fácilmente disponibles o accesibles, son los que más beneficiaron de este tipo de intervenciones específicas para reducir las tasas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B771. (Traducción-Dr. Xavier Delgadillo).

Does Bowel Function Change After Colectomy for Colon Malignancy?

BACKGROUND: Colon cancer patients often ask how surgery will affect bowel function. Current understanding is informed by conflicting data, making preoperative patient counseling difficult. We aimed to evaluate patient-reported bowel function changes after colectomy for colon malignancy. MATERIAL AND METHODS: This was a retrospective analysis of a prospectively collected institutional database from July 2015 to June 2019. The included patients underwent colectomy for adenocarcinoma of the colon, and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative presentation and postoperative followup. Preoperative and postoperative scores were compared using paired t-tests. Multivariable analysis was performed using domains demonstrating statistical significance on bivariate analysis, assessing the factors that were associated with symptomatic bowel function. RESULTS: We identified 117 patients with a mean age of 64 ± 13 y. The median time between preoperative and postoperative questionnaire completion was 52 d (interquartile range 45-70). Bowel movement frequency increased significantly from a mean preoperative score of 9.72 to a mean postoperative score of 14.2 (P = 0.003). There were no significant differences in the remaining four domains of bowel function or global function. Multivariable analysis demonstrated higher likelihood of symptomatic postoperative frequency scores in male patients (OR 3.85, 95% CI 1.44-11.11, P = 0.007) and patients with symptomatic preoperative frequency (OR 5.56, 95% CI 1.62-19.02, P = 0.006). CONCLUSIONS: Patient-reported bowel movement frequency worsens at postoperative follow-up after colectomy for colon cancer, while overall bowel function does not change. Men and patients with preoperative symptomatic frequency have an increased likelihood of reporting symptomatic postoperative frequency. These findings should guide more personalized and evidence-based preoperative patient counseling.

Prospective Evaluation of a Standardized Opioid Reduction Protocol after Anorectal Surgery.

BACKGROUND: Surgery for anorectal disease is thought to cause significant postoperative pain. Our previous work demonstrated that most opioids prescribed after anorectal surgery are not used. We aimed to evaluate a standardized protocol for pain control after anorectal surgery. METHODS: We prospectively evaluated a standardized opioid reduction protocol over a 13-mo period for all patients undergoing elective anorectal surgery at our institution. Protocol components include preoperative query, procedural local-anesthetic blocks, first-line nonopioid analgesic use ± opioid prescription of five pills, and standardized postoperative instructions. Patients completed questionnaires at postoperative follow-up. Patients with history of opioid abuse or use within 30 d of operation, loss to follow-up, or surgical complications were excluded. Primary outcome was quality of pain control on a five-point scale. Secondary outcomes included use of nonopioid analgesics, opioids used, and need for refill. RESULTS: A total of 55 patients were included. Mean age was 47 ± 17 y with 23 women (42%). Anorectal abscess/fistula procedures were the most common (69%) followed by pilonidal procedures (11%) and hemorrhoidectomy (7%). Most had general anesthesia (60%) with the remainder local anesthesia ± sedation. Fifty-four (98%) had procedural local-anesthetic blocks. Twenty-six patients (47%) were prescribed opioids with a median of five pills. Forty-seven patients (85%) reported the use of nonopioid analgesics. Forty-six patients (84%) reported excellent to very good pain control. About 220 opioid pills were prescribed, and 122 were reported to be used. One patient (2%) received an opioid refill. CONCLUSIONS: Satisfactory pain control after anorectal surgery can be achieved with multimodality therapy with little to no opioid use for most patients.

Parastomal hernia development after cystectomy and ileal conduit for bladder cancer: results from the Dartmouth ileal conduit enhancement (DICE) project.

INTRODUCTION Limited information exists regarding parastomal hernia development in bladder cancer patients. The purpose of this investigation was to describe the natural history of parastomal hernias and identify risk factors for hernia development in patients who undergo cystectomy with ileal conduit urinary diversion. MATERIALS AND METHODS: A retrospective cohort study was performed of bladder cancer patients who underwent cystectomy with ileal conduit urinary diversion between January 1st 2009 and July 31st 2018 at Dartmouth-Hitchcock Medical Center. The primary outcome of interest was the presence of a parastomal hernia as evident on postoperative cross-sectional imaging obtained for disease surveillance. RESULTS: A total of 107 patients were included with a mean age of 70.9 years and 29.9% being female. Parastomal hernias were identified in 68.2% of bladder cancer patients who underwent cystectomy with ileal conduit urinary diversion. Forty percent of patients with a parastomal hernia reported symptoms related to their hernia, while 12.5% underwent operative repair. After multivariate adjustment, patients with a postop body mass index (BMI) > 30 kg/m² (odds ratio [OR]: 21.8, 95% CI: 1.6-305.2) or stage III or IV bladder cancer (OR: 18, 95% CI: 2.1-157.5), had significantly greater odds of parastomal hernia development. Fifty percent of parastomal hernias were identified 1.3 years from surgery, while 75% were identified by 2 years after cystectomy. CONCLUSION: Parastomal hernias developed in over two-thirds of bladder cancer patients and occurred rapidly following cystectomy and ileal conduit urinary diversion. Greater postoperative BMI and bladder cancer stage were identified as significant risk factors for parastomal hernia development. Significant opportunity exists to reduce morbidity associated with parastomal hernias in this population.

Effect of Elective Sigmoidectomy for Diverticulitis on Bowel Function Patient-Reported Outcomes.

INTRODUCTION: Diverticular disease is common worldwide. A subset of these patients will choose to undergo elective surgical resection because of symptoms or complicated disease. The aim of this study was to evaluate changes in bowel function after elective sigmoid resection for diverticular disease. MATERIALS AND METHODS: We retrospectively reviewed patients seen at our institution from May 2015 to July 2018 who underwent elective sigmoid resection for diverticular disease. We used the Colorectal Functional Outcome (COREFO) questionnaire, a validated questionnaire that assesses bowel function in five domains and a global function score (scores 0-100, with higher score indicating worse function). We obtained questionnaire data at baseline, as well as at postoperative follow-up, and a paired t-test was used to compare. RESULTS: Forty-nine patients met criteria for inclusion in this study. The median time between questionnaire completion was 70 days (interquartile range: 56 to 85). The mean age was 60 ± 12 years, with 57% female patients. Thirty-six (73%) patients underwent sigmoidectomy alone and 13 (27%) underwent sigmoidectomy with fistula repair. Six patients (12%) had a diverting loop ileostomy in addition to sigmoidectomy and underwent a subsequent reversal. Overall, there were no differences in any of the five domains or the total Colorectal Functional Outcome score from baseline to postintervention. CONCLUSIONS: In our cohort, bowel function did not significantly change in the early postoperative period after elective sigmoid resection for diverticular disease. Surgeons should counsel patients, especially symptomatic ones, that bowel function will likely be no different at time of postoperative follow-up.

The Effect of Nonoperative Management of Chronic Anal Fissure and Hemorrhoid Disease on Bowel Function Patient-Reported Outcomes.

BACKGROUND: Nonoperative management has been reported to decrease symptoms from common anorectal conditions such as chronic anal fissures and hemorrhoids. The effects of these interventions on bowel function are unknown. OBJECTIVE: This study aims to perform a prospective evaluation of patient-reported outcomes of bowel function on nonoperative management for chronic anal fissures and hemorrhoid disease. DESIGN: This is a prospective, observational study. SETTINGS: Patient-reported outcome measures were collected from the clinical practice of the division of colon and rectal surgery at a tertiary colon and rectal surgery referral center. INTERVENTION: All patients received standardized dietary counseling including fiber supplementation as well as toileting strategies. Those with chronic anal fissures were also prescribed topical calcium channel blockers. The Colorectal Functional Outcome questionnaire was administered at baseline and at first follow-up visit. MAIN OUTCOME MEASURES: The primary outcomes measured were the mean change in patient-reported bowel function scores after nonoperative management for each disease and in aggregate. RESULTS: A cohort of 64 patients was included, 37 patients (58%) with chronic anal fissure and 27 patients with hemorrhoid disease. Incontinence, social impact, stool-related aspects, and the global score were observed to have statistically significant improvement in the aggregate group. When analyzed by diagnosis, hemorrhoid disease demonstrated a statistically significant improvement in incontinence and stool-related aspects, whereas chronic anal fissure was associated with a statistically significant change in social impact, stool-related aspects, and the global score. LIMITATIONS: This study was limited by the small cohort size and unclear patient adherence to medical management. CONCLUSIONS: Nonoperative management of chronic anal fissures and hemorrhoid disease is associated with significant improvement in patient-reported outcome scores in several domains, suggesting that dietary counseling and medical therapy should be the first-line outpatient therapy for these diseases. See Video Abstract at http://links.lww.com/DCR/A726.

Ulcerative Colitis Is Associated With an Increased Risk of Venous Thromboembolism in the Postoperative Period: The Results of a Matched Cohort Analysis.

OBJECTIVES: To determine the rates of venous thromboembolism (VTE) during admission and within 30 days of hospital discharge in inflammatory bowel (IBD) patients undergoing colonic resection using the ACS National Surgical Quality Improvement Project (NSQIP) database and to compare these rates to VTE rates in cohorts of patients undergoing colonic resection for several other colonic pathologies. BACKGROUND: High rates of VTE have been demonstrated in hospitalized IBD patients. However, rates of postdischarge VTE in IBD patients are understudied. METHODS: Demographic, operative, and outcomes data for 96,999 patients undergoing colonic resection for diverticulitis, colorectal cancer (CRC), benign neoplasms, ulcerative colitis (UC), and Crohn's disease (CD) between 2005 and 2011 was obtained. Student t and χ tests were used for univariate analysis. A logistic multivariate analysis was performed with all significant variables. Propensity score matching was utilized to compare the VTE incidences between the groups. RESULTS: Highest VTE risk was seen in obese patients [odds ratio (OR) = 1.41], those older than 73 years (OR = 1.58) and with bleeding disorders (OR = 1.44), American Society of Anesthesiology class III/IV (OR = 1.52/1.86), preoperative systemic inflammatory response syndrome (OR = 1.55), sepsis (OR = 1.48) or steroid use (OR = 1.63), and primary diagnosis of UC (OR = 2.10). The UC group had the highest incidence of VTE (2.74%), followed by CRC patients (1.74%). A 1.2% incidence was seen in the CD population, and 41.5% of the UC-VTEs were diagnosed after discharge. CONCLUSIONS: This study affirms that inpatient UC patients undergoing colonic resection are at high risk for VTE and suggests that this risk persists into the postdischarge period. Thus, these patients should be given appropriate prophylaxis.

How do risk factors for mortality and overall complication rates following laparoscopic and open colectomy differ between inpatient and post-discharge phases of care? A retrospective cohort study from NSQIP.

BACKGROUND: Risk factors for complications differ between laparoscopic (LC) and open colectomy (OC) patients, given the selection bias between these groups. How risk factors for these outcomes differ between inpatient and post-discharge phases of care requires further study. METHODS: A retrospective cohort study (2005-2010) using NSQIP data was performed comparing OC and LC patients. Multivariable logistic regression was used to compare covariates associated with mortality and overall complication rates both before and after hospital discharge. RESULTS: Patients in the LC cohort were younger (64.2 vs. 62.5 years; P < 0.0001) with a lower incidence of comorbidities. OC was associated with a higher incidence of mortality compared to LC among inpatients (3.3 vs. 0.61%, P < 0.0001) and following discharge (0.88 vs. 0.29%, P < 0.0001). OC also demonstrated a higher incidence of overall complication rates for both inpatients (22.32 vs. 9.36%, P < 0.0001) and following discharge (8.83 vs. 7.24%, P < 0.0001). Risk factors (P < 0.05) for mortality following LC included age and emergency procedures for inpatients; pre-operative SIRS was associated with mortality occurring after discharge. For the OC cohort, risk for mortality was increased with smoking and contaminated/dirty wounds for inpatients; pre-operative weight loss was associated with death following discharge. Factors associated with increased risk of morbidity following LC included smoking history for inpatients and pre-operative steroid therapy following discharge. Following OC, morbidity was strongly associated with ASA scores for inpatients; pre-operative steroid therapy was a risk factor following discharge. Obesity was strongly associated with non-mortal complications in both cohorts following discharge. CONCLUSIONS: (1) LC is associated with a lower incidence of post-operative mortality and complications. (2) Risk factors associated with adverse post-operative outcomes change during the post-operative period; surveillance for these outcomes should be tailored by operative technique and phase of post-operative care (3) Obesity is an underappreciated risk for complications following discharge for both LC and OC.

Analysis of clinically significant seroma formation in breast reconstruction using acellular dermal grafts.

With a rise in tissue expander-based breast reconstructions (TEBRs) using acellular dermal matrix (ADM), we have seen an increase in ADM-specific complications. In this study, we aimed to evaluate clinically significant seroma (CSS) formation-defined by the need for a drainage procedure-to determine if there was a difference in incidence between product types: AlloDerm (AL), DermaMatrix (DM), and FlexHD (FHD). This was a retrospective review of consecutive patients who underwent TEBR at a single institution. The total number of reconstructed breasts was separated into the following 4 groups according to the product type: AL, DM, FHD, or no ADM. We identified the total number of CSSs and compared these data between product types. A logistic regression was performed in an attempt to identify independent risk factors associated with seroma formation. In total, we identified 284 consecutive TEBRs. Overall, there were 17 (7.7%) seromas in 220 breast reconstructions in which ADM was used. When comparing the number of CSS between groups-AL (n = 2, 4.0%), DM (n = 6, 5.4%), FHD (n = 9, 14.75%), and no ADM (n = 1, 1.5%)-we found a significant difference in seroma incidence between product types (P = 0.016). Multivariate analysis identified a strong trend toward FHD as an independent predictor of seroma formation (P = 0.061). Our review suggests that there is strong trend in CSS formation with the use of FHD as compared to other product types and reconstructions in which no ADM was used.

Mental health diagnosis, not patient-reported outcomes, is predictive of failing to meet the expected outcomes after successful implementation of an Enhanced Recovery After Surgery Protocol after elective colon resection.

BACKGROUND: Enhanced Recovery After Surgery protocols have demonstrated decreased complication rates and length of stay. However, the influence of mental health on Enhanced Recovery After Surgery success is unknown. METHOD: A retrospective study of patient-reported outcomes for physical and mental health. We included patients who underwent elective minimally invasive colon resections, who completed the Patient-Reported Outcomes Measurement Information System 10 questionnaire preoperatively, and who had successful implementation of perioperative Enhanced Recovery After Surgery components. We evaluated the predictors of having successful expected Enhanced Recovery After Surgery outcomes using a multiple logistic regression, controlling for baseline patient characteristics, history of a mental health diagnosis, inpatient opiate use, and preoperative Patient-Reported Outcomes Measurement Information System 10 scores. RESULTS: In total, 163 patients met inclusion criteria, with 23% failing Enhanced Recovery After Surgery, and 32% having a preoperative mental health diagnosis. The most common reason for failure of expected Enhanced Recovery After Surgery outcomes was length of stay (55.3%) followed by postoperative ileus (31.6%). Age, sex, the American Society of Anesthesiologists physical status classification, and preoperative Patient-Reported Outcomes Measurement Information System 10 scores were not significantly different between those who failed or succeeded, whereas length of stay was typically longer for those who failed Enhanced Recovery After Surgery (5.7 days failure vs 2.2 days success, P < .001). Patients with a previous mental health diagnosis, where depression and anxiety were most common, had significantly lower odds of successfully meeting expected Enhanced Recovery After Surgery outcomes (odds ratio of 0.23, 95% confidence interval: 0.09-0.55, P = .001). CONCLUSION: Patients with a mental health diagnosis have a lower likelihood of successfully meeting expected Enhanced Recovery After Surgery outcomes. The majority of these patients self-report normal mental and physical health preoperatively, indicating that even well-controlled mental health diagnoses have a negative impact on Enhanced Recovery After Surgery success.

Restorative reconstruction after total mesorectal excision for rectal cancer is associated with significant bowel dysfunction from initial presentation.

BACKGROUND: Patients often desire restorative reconstruction following total mesorectal excision. Reconstruction has become synonymous with providing high-quality rectal cancer care. However, the bowel functional outcomes of restoration from presentation are unknown. We aimed to evaluate the bowel functional effects of rectal cancer treatment from presentation through surveillance. METHODS: This was a retrospective cohort study from 2014 to 2019 using prospectively collected data. Patients underwent treatment for rectal adenocarcinoma including restorative reconstruction. Patients completed the validated Colorectal Functional Outcome questionnaire during clinic visits (1) at presentation, (2) after neoadjuvant therapy, (3) after restoration of continuity, and (4) at surveillance. Scores range from 0 to 100 with a higher score indicating worse bowel function. RESULTS: Sixty-eight patients (age: 62 ±â€¯12 years, 40% female) were included. The mean tumor height was 7 ±â€¯4 cm with 85% symptomatic. Bowel function did not worsen from presentation to after neoadjuvant therapy in Total Colorectal Functional Outcome and most domain scores; there was improvement in frequency and stool-related aspects. Bowel function worsened in all scores from after neoadjuvant to restoration of continuity (mean anastomotic height: 5 ±â€¯2 cm); there were similar findings between presentation and restoration of continuity. At surveillance, there was improvement in most domains compared with restoration of continuity. There remained significant worsening of incontinence, social impact, and need for medication scores at surveillance compared with presentation. CONCLUSION: Restorative reconstruction after total mesorectal excision is associated with significant bowel dysfunction. For some patients, restorative reconstruction may not be high-quality rectal cancer care.

Autologous Fascia Lata for Combined Sacrocolpopexy and Rectopexy.

ABSTRACT: We present a case series and video of our technique using autologous fascia lata for combined sacrocolpopexy and rectopexy, with or without resection.