Clinical Characteristics and Outcomes of Colorectal Cancer in the ColoCare Study: Differences by Age of Onset.

Early-onset colorectal cancer has been on the rise in Western populations. Here, we compare patient characteristics between those with early- (<50 years) vs. late-onset (≥50 years) disease in a large multinational cohort of colorectal cancer patients (n = 2193). We calculated descriptive statistics and assessed associations of clinicodemographic factors with age of onset using mutually-adjusted logistic regression models. Patients were on average 60 years old, with BMI of 29 kg/m2, 52% colon cancers, 21% early-onset, and presented with stage II or III (60%) disease. Early-onset patients presented with more advanced disease (stages III-IV: 63% vs. 51%, respectively), and received more neo and adjuvant treatment compared to late-onset patients, after controlling for stage (odds ratio (OR) (95% confidence interval (CI)) = 2.30 (1.82-3.83) and 2.00 (1.43-2.81), respectively). Early-onset rectal cancer patients across all stages more commonly received neoadjuvant treatment, even when not indicated as the standard of care, e.g., during stage I disease. The odds of early-onset disease were higher among never smokers and lower among overweight patients (1.55 (1.21-1.98) and 0.56 (0.41-0.76), respectively). Patients with early-onset colorectal cancer were more likely to be diagnosed with advanced stage disease, to have received systemic treatments regardless of stage at diagnosis, and were less likely to be ever smokers or overweight.

A prospective evaluation of the ligation of the intersphincteric tract procedure for complex anal fistula in patients with Crohn's disease.

OBJECTIVE: To evaluate 2- and 12-month outcomes after ligation of the intersphincteric fistula tract (LIFT) in Crohn's disease (CD). BACKGROUND: Surgical approaches to perianal fistulas in CD are frequently ineffective and hampered by concerns over adequate wound healing and sphincter injury. The efficacy of LIFT in CD patients is unknown. METHODS: Consecutive cases of CD patients with transsphincteric fistulas were prospectively analyzed. Fistula healing and 2 validated quality-of-life indices were assessed. RESULTS: Fifteen CD patients (9 women; mean age = 34.8 years) were identified. Location of the fistula was lateral (n = 10; 67%) or midline (n = 5; 33%). LIFT site healing was seen in 9 patients (60%) at 2-month follow-up. No patient developed fecal incontinence. LIFT site healing was seen in 8 of the 12 patients (67%) with complete 12-month follow-up. Significant factors for long-term LIFT site healing were lateral versus midline location (P = 0.02) and longer mean fistula length (P = 0.02). Patients who had successful operations significantly improved both their mean Wexner Perianal Crohn's Disease Activity Index and McMaster Perianal Crohn's Disease Activity Index quality-of-life scores at 2-month follow-up (14.0-3.8, P = 0.001, and 10.4-1.8, P = 0.0001, respectively). CONCLUSIONS: CD-associated anal fistulas may be treated with LIFT. This surgical procedure is a safe, outpatient procedure that minimizes both perianal wound creation and sphincter injury.

Does prophylactic subcutaneous heparin increase the risk of wound infection after colorectal surgery?

Chemical prophylaxis using unfractionated heparin (UH) and low-molecular weight heparin is used in surgical patients to prevent venous thromboembolism. There is some evidence that prophylactic doses of heparin may increase the rate of surgical site infection (SSI) after elective orthopedic procedures. Little is known regarding the effect of heparin on SSI after colorectal procedures. We performed this study to study the effect of prophylactic unfractionated heparin on the rate of SSI after colorectal procedures. We did a retrospective analysis of 155 consecutive cases of patients of a single colorectal surgeon who underwent colorectal resection. Subcutaneous unfractionated heparin was given to 52 patients (29%). The rate of SSI in the group that received UH was 33 per cent versus 28 per cent in the group that did not receive UH (P = 0.31). There was also no significant effect of prophylactic heparin on SSI noted among any patient subgroup. The use of prophylactic unfractionated heparin after colorectal procedures does not seem to increase the rate of surgical site infection.

A prospective evaluation of the long-term outcome of ileal pouch-anal anastomosis in patients with inflammatory bowel disease-unclassified and indeterminate colitis.

PURPOSE: The long-term outcome of ileal pouch-anal anastomosis in patients with indeterminate colitis is controversial. The aim of this study was to prospectively evaluate the long-term outcome of ileal pouch-anal anastomosis in a closely monitored cohort of patients with ulcerative colitis or indeterminate colitis. METHODS: Prospectively generated clinical profiles on consecutive patients with ulcerative colitis or indeterminate colitis undergoing ileal pouch-anal anastomosis with close postoperative follow-up by one surgeon were reviewed. All patients were classified before surgery as either ulcerative colitis or inflammatory bowel disease-unclassified, and after surgery as either ulcerative colitis or indeterminate colitis. Long-term outcomes included acute pouchitis (antibiotic responsive), chronic pouchitis (antibiotic dependent or refractory), or de novo Crohn's disease (small inflammation above the pouch inlet or pouch fistula). RESULTS: The study cohort of 334 patients were classified before surgery as ulcerative colitis in 237 (71 percent) and inflammatory bowel disease-unclassified in 97 (29 percent). After surgery, patients were classified as ulcerative colitis in 236 (71 percent) and indeterminate colitis in 98 (29 percent). After a median follow-up after stoma closure of 26 months, 53 patients (16 percent) developed acute pouchitis, 37 patients (11 percent) developed chronic pouchitis, and 40 patients (12 percent) developed de novo Crohn's disease. There was no significant difference in the incidence of acute pouchitis, chronic pouchitis, or de novo Crohn's disease between the ulcerative colitis, inflammatory bowel disease-unclassified, and indeterminate colitis patient groups. CONCLUSION: The incidence of acute pouchitis, chronic pouchitis, and de novo Crohn's disease after ileal pouch-anal anastomosis do not differ significantly between patients with ulcerative colitis, inflammatory bowel disease-unclassified, or indeterminate colitis. Patients with inflammatory bowel disease-unclassified and indeterminate colitis can undergo ileal pouch-anal anastomosis and expect a long-term outcome equivalent to patients with ulcerative colitis.

Outcomes of right and left colectomy at academic centers.

Few studies have compared outcomes of right colectomy (RC) and left colectomy (LC) with respect to both benign and malignant disease. The objective of this study was to compare outcomes of RC versus LC for benign and malignant disease using a national administrative database of academic medical centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, data was obtained from the University HealthSystem Consortium Clinical Data Base for patients that underwent RC and LC for benign and malignant disease between 2002 and 2006. The main outcomes compared were demographics, length of hospital stay, observed to expected in-hospital mortality, complications, 30-day readmission, and mean cost. There were a total of 27,483 patients; 12,971 patients (47.2%) underwent RC. Compared with LC for benign disease, RC was associated with a shorter length of stay, lower overall complications, lower wound infections, lower 30-day readmissions, and lower cost. Compared with LC for malignant disease, RC was associated with lower overall complications, lower wound infections, and lower cost. In this analysis of academic centers, RC was associated with a lower length of stay, lower morbidity, and lower cost when compared with LC for benign and malignant disease.

Comparison of laparoscopic vs open sigmoid colectomy for benign and malignant disease at academic medical centers.

Few studies have examined outcomes of laparoscopic and open sigmoid colectomy performed at US academic centers. Using ICD-9 diagnosis and procedural codes, data was obtained from the University HealthSystem Consortium (UHC) Clinical Database of 10,603 patients who underwent laparoscopic or open sigmoid colectomy for benign and malignant disease between 2003-2006. A total of 1,092 patients (10.3%) underwent laparoscopic sigmoid colectomy. Laparoscopic sigmoid colectomy was associated with a significantly shorter length of stay (5.4 vs 7.4 days), lower overall complication rate (19.7 vs 26.0%), lower 30-day readmission rate (3.4 vs 4.6), and a lower hospital cost ($13,814 vs $15,626). When a subset analysis of malignant and benign groups was performed, a significantly shorter length of stay in both the malignant laparoscopic group (6.4 +/- 6.4 vs 7.8 +/- 6.6 days) and in the benign laparoscopic groups (5.1 +/- 3.5 vs 7.2 +/- 7.6) exists. A lower wound complication rate (2.1 vs 5.5%, malignant and 4.0 vs 6.1, benign) is also evident. Laparoscopic sigmoid colectomy was associated with a shorter length of stay, less complications, and a lower 30-day readmission rate. The shorter length of stay and wound infection rate maintain significance when comparing laparoscopic vs open sigmoid resections for malignant and benign disease.

Reoperation for anastomotic failure.

Anastomotic leak is a dreaded complication of colorectal surgery, with many potential causes. This complication carries with it a reported mortality ranging from 6 to 39%. Early diagnosis is key for the prevention of mortality. Here, we discuss the causes of an anastomotic leak and its signs and symptoms. Moreover, we explore the various modalities of diagnosis and treatment options. Most important, we discuss when a patient needs to be taken to the operating room and what procedure should be performed given various intraoperative findings.

Contemporary indications for and early outcomes of abdominoperineal resection.

The purpose of this study was to review and characterize the indications and early outcomes of abdominoperineal resection (APR) when used in a colorectal practice in an academic setting. Data was collected from the charts of all patients undergoing APR in a retrospective manner. Data collected included demographic information and details regarding the clinical presentation. Operative factors, information regarding the postoperative course, and morbidity and mortality were evaluated. Forty-four patients were treated with an APR in this practice between the years 1992 and 2004. The indications for operation were primary rectal cancer (n = 31), recurrent rectal cancer (n = 6), intractable Crohn disease (n = 3), anal melanoma (n = 1), cloacogenic cancer (n = 1), squamous cell cancer (n = 1), and gastrointestinal stromal tumor (n = 1). Complications in the first 60 days affected 14 patients (32%). The most common complication was intra-abdominal/pelvic abscess formation occurring in 6 of these 14 patients (43%). Additional complications in the first 60 days included rectus flap necrosis, perineal wound evisceration, prolonged ileus, and urinary retention. There was no surgical mortality. Long-term complications occurred in 7 patients (16%), with parastomal hernia being the most common (43%). Although relatively infrequently used, APR will continue to play a role for selected patients in the future. Despite the significant morbidity associated with this surgery, APR may provide beneficial treatment for select cases of low rectal cancer, end-stage inflammatory bowel disease, and anal malignancies.