Surgical Outcomes in Total Neoadjuvant Therapy for Rectal Cancer Versus Standard Long-course Chemoradiation: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: This systematic review and meta-analysis seeks to evaluate the impact of total neoadjuvant therapy (TNT) for rectal cancers on surgical complications and surgical pathology when compared with standard long-course chemoradiotherapy (LCRT). BACKGROUND: The oncological benefits of TNT are well published in previous meta-analyses, but there is little synthesized information on how it affects surgical outcomes. A recent study has suggested an increase in local recurrence and higher rates of breached total mesorectal excision (TME) plane in TNT patients. METHODS: This study conformed to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A search was performed in Medline (via PubMed), Cochrane databases, EMBASE and CINAHL to identify relevant randomized controlled trials (RCTs) comparing outcomes between TNT and LCRT. Meta-analyses of pooled proportions between TNT and LCRT were performed, comparing primary outcomes of surgical mortality, morbidity and all reported complications; surgical-pathology differences, namely mesorectal quality, R0 resection rates, circumferential resection margin positive rates, and sphincter preservation rates. Death and progression of disease during neoadjuvant treatment period was also compared. Risk of bias of RCTs was performed using the Cochrane risk-of-bias tool by 2 independent reviewers. RESULTS: A total of 3185 patients with rectal cancer from 11 RCTs were included in the analysis: 1607 received TNT and 1578 received LCRT, of which 1422 (TNT arm) and 1391 (LCRT arm) underwent surgical resection with curative intent. There was no significant difference in mortality [risk ratio (RR)=0.86, 95% CI: 0.13-5.52, P =0.88, I2 =52%] or major complications (RR=1.04, 95% CI: 0.86-1.26, P =0.70, I2 =0%) between TNT and LCRT. There was a significantly higher risk of breached TME in TNT group on pooled analysis (RR=1.49, 95% CI: 1.03-12.16, P =0.03, I2 =0%), and on subgroup analysis there is higher risk of breached TME in those receiving extended duration of neoadjuvant treatment (>17 weeks from start of treatment to surgery) when compared with LCRT (RR=1.61, 95% CI: 1.06-2.44, P =0.03). No difference in R0 resection rates (RR=0.85, 95% CI: 0.66-1.10, P =0.21, I2 =15%), circumferential resection margin positive rates (RR=0.87, 95% CI: 0.65-1.16, P =0.35, I2 =10%) or sphincter preservation rates (RR=1.02, 95% CI: 0.83-1.25, P =0.88, I2 =57%) were observed. There was a significantly lower risk of progression of disease to an unresectable stage during the neoadjuvant treatment period in TNT patients (RR=0.60, 95% CI: 0.39-0.92, P =0.03, I2 =18%). On subgroup analysis, it appears to favor those receiving extended duration of neoadjuvant treatment (RR=0.44, 95% CI: 0.26-0.80, P =0.002), and those receiving induction-type chemotherapy in TNT (RR=0.25, 95% CI: 0.07-0.88, P =0.03). CONCLUSIONS: TNT increases rates of breached TME which can contribute to higher local recurrence rates. TNT, however, improves systemic control by reducing early progression of disease during neoadjuvant treatment period. Further research is warranted to identify patients that will benefit from this strategy.

Local Recurrence-Free Survival After TaTME: A Canadian Institutional Experience.

BACKGROUND: Transanal total mesorectal excision is a novel surgical treatment for mid to low rectal cancers. Norwegian population data have raised concerns about local recurrence in patients treated with transanal total mesorectal excision. OBJECTIVE: This study aimed to analyze local recurrence and disease-free survival in patients treated by transanal total mesorectal excision for rectal cancer at a high-volume tertiary center. DESIGN: This retrospective study used a prospectively maintained institutional transanal total mesorectal excision database. Patient demographics, treatment, and outcomes data were analyzed. Local recurrence, disease-free survival, and overall survival were analyzed using Kaplan-Meier analysis. SETTINGS: The study was conducted at a single academic institution in Vancouver, Canada. PATIENTS: All patients treated by transanal total mesorectal excision for rectal adenocarcinoma between 2014 and 2022 were included. MAIN OUTCOME MEASURES: The primary outcome was local recurrence-free survival. RESULTS: Between 2014 and 2022, 306 patients were treated by transanal total mesorectal excision at St. Paul's Hospital. Of these, 279 patients met the inclusion criteria. The mean age was 62 years (SD ± 12.3), and 66.7% of patients were men. Restorative resection was achieved in 97.5% of patients, with a conversion rate from laparoscopic to open surgery of 6.8%. The composite optimal pathological outcome was 93.9%. The median follow-up was 26 months (interquartile range, 12-47), and 82.8% of patients achieved reestablishment of GI continuity to date. The overall local recurrence rate was 4.7% (n = 13). The estimated 2-year local recurrence-free survival rate was 95.0% (95% CI, 92-98) and the estimated 5-year local recurrence-free survival rate was 94.5% (95% CI, 91-98). LIMITATIONS: Limitations include the retrospective nature of the study and the generalizability of a Canadian population. CONCLUSIONS: Recent European data have challenged the presumed oncologic safety of transanal total mesorectal excision. Although the learning curve for this procedure is challenging and poor outcomes are associated with low volume, this high-volume single-center study confirms acceptable oncologic outcomes consistent with the current standard. See Video Abstract . SOBREVIDA SIN RECIDIVA DESPUS DE TATME EXPERIENCIA INSTITUCIONAL CANADIENSE: ANTECEDENTES:La excisión total del mesorecto por vía transanal es un tratamiento quirúrgico novedoso para los cánceres de recto medio a bajo. Estudios sobre la población noruega han generado preocupación debido a la recidiva local en pacientes tratados con excisión total del mesorecto por vía transanal.OBJETIVO:Nuestra finalidad fué de analizar la recidiva local y la sobrevida libre de enfermedad en pacientes tratados mediante la excisión total del mesorecto por vía transanal, debido a un cáncer de recto en un centro terciario de alto volúmen.DISEÑO:El presente estudio retrospectivo, utiliza una base de datos institucional sobre la excisión total del mesorecto por vía transanal mantenida prospectivamente. Se analizaron los datos demográficos, de tratamiento y los resultados de los pacientes sometidos a la técnica mencionada. La recidiva local, la sobrevida libre de enfermedad y la sobrevida global se analizaron mediante el modelo de Kaplan-Meier.AJUSTES:El estudio se llevó a cabo en una sola institución académica en Vancouver, Canadá.PARTICIPANTES:Se incluyeron todos los pacientes tratados mediante excisión total del mesorecto por vía transanal causado por adenocarcinomas de recto entre 2014 y 2022.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la sobrevida libre de recidiva local.RESULTADOS:Entre 2014 y 2022, 306 pacientes fueron tratados mediante la excisión total del mesorecto por vía transanal en el Hospital St. Paul. De estos, 279 pacientes cumplieron los criterios de inclusión. La edad media fue de 62 años (DE ± 12,3) y el 66,7% de los pacientes eran varones. La resección restauradora se logró en el 97,5% de los pacientes con una tasa de conversión de cirugía laparoscópica en laparotomía del 6,8%. El resultado patológico óptimo combinado fué del 93,9%. La mediana de seguimiento fue de 26 meses (rango intercuartil 12-47) y el 82,8% logró el restablecimiento de la continuidad gastrointestinal hasta la fecha. La tasa global de recidiva local fué del 4,7% (n = 13). La sobrevida libre de recidiva local estimada a los 2 años fué del 95,0% (IC del 95%: 92-98) y del 94,5% a los 5 años (IC del 95%: 91-98).LIMITACIONES:Las limitaciones incluyen la naturaleza retrospectiva del estudio y la generalización de una población canadiense.CONCLUSIONES:Datos europeos recientes han cuestionado la supuesta seguridad oncológica de la excisión total del mesorecto por vía transanal. Si bien la curva de aprendizaje de este procedimiento es muy desafiante y los malos resultados se asocian con un volumen bajo, el presente estudio, unicéntrico de gran volumen confirma los resultados oncológicos aceptables consistentes con el estándar actual. (Traducción-Dr. Xavier Delgadillo ).

Safety and Efficacy of Iltamiocel Cellular Therapy for the Treatment of Fecal Incontinence. Results of a Phase 1/2 Study.

OBJECTIVE: To examine the safety and efficacy of iltamiocel, an investigational cellular therapy of autologous muscle-derived cells, as a treatment for fecal incontinence (FI) in adults. BACKGROUND: Limited therapeutic options are available for patients with FI refractory to conservative treatments. Cell therapy using autologous muscle-derived cells represents a promising, minimally invasive approach for restoring anal sphincter function. METHODS: In this multicenter, prospective, non-randomized study, 48 participants were treated with a single iltamiocel dose of 250×10 6 cells. The primary outcome was the incidence of product or procedure-related adverse events (AEs) and serious AEs. Secondary outcomes were changes in the number of FI episodes, Cleveland Clinic Incontinence Score, Fecal Incontinence Quality of Life, and anorectal manometry at 3, 6, and 12 months compared to baseline. RESULTS: No serious AEs and only one product-related AE of inflammation at the injection site were reported. At 12 months, there was a reduction in median FI episodes (-6.0; 95% confidence interval (CI): -10.0, -1.0) and days with episodes (-4.0; 95% CI: -8.0, -1.0). A ≥50% reduction in FI episodes was observed in 53.7% of participants, and 24.4% had complete restoration of continence. Symptom severity and quality of life improved with mean Cleveland Clinic Incontinence Score reduction (-2.9; 95% CI: -3.7, -2.1), and Fecal Incontinence Quality of Life increased (2.2; 95% CI:1.4, 2.9). No significant changes were detected in anorectal manometry measurements. A history of episiotomy was significantly associated with treatment response in multivariate analysis. CONCLUSION: The administration of iltamiocel cellular therapy is safe. Iltamiocel shows promise for significantly improving fecal incontinence symptoms and quality of life.

Management of rectal neuroendocrine tumours by transanal endoscopic microsurgery.

AIM: The objective of this study was to evaluate the safety and effectiveness of transanal endoscopic microsurgery for rectal neuroendocrine tumours. METHOD: A retrospective cohort study of all pathology-confirmed rectal neuroendocrine tumours treated by transanal endoscopic microsurgery from April 2007 to December 2020 at a tertiary care centre was performed. Demographic, clinical, radiographic and pathological data were collected. Characteristics of patients with recurrence were examined. Descriptive statistics were performed. RESULTS: There were 58 patients treated by transanal endoscopic microsurgery excision. Referrals were for primary excision (15, 25.9%), completion re-excision after incomplete endoscopic removal (38, 65.5%) or locally recurrent rectal neuroendocrine tumours (5, 8.6%). The mean age of patients was 56.4 ± 11.9 years and 26 patients were women (44.8%). Mean tumour size was 7.4 ± 3.8 mm (range 1.0-15.0 mm). Most (86.4%) were Grade 1 tumours. Mean operative time was 37.2 ± 17.2 min and 56 patients (96.6%) were discharged on the same day. All patients had negative margins on final pathology. Of the 38 patients who were referred for completion re-excision after incomplete endoscopic removal, eight (21.1%) had residual tumour on final pathology. Three recurrences were diagnosed at 2.1, 4.5 and 12.5 years after excision. All recurrences were from Grade 1 or 2 primary tumours, less than 2 cm, and diagnosed radiographically. CONCLUSION: To date, this is the largest North American study looking at transanal endoscopic microsurgery for rectal neuroendocrine tumours. This technique is effective in managing primary, incompletely excised and recurrent tumours with good clinical and oncological outcomes.

Local versus radical surgery for early rectal cancer with or without neoadjuvant or adjuvant therapy.

BACKGROUND: Total mesorectal excision is the standard of care for stage I rectal cancer. Despite major advances and increasing enthusiasm for modern endoscopic local excision (LE), uncertainty remains regarding its oncologic equivalence and safety relative to radical resection (RR). OBJECTIVES: To assess the oncologic, operative, and functional outcomes of modern endoscopic LE compared to RR surgery in adults with stage I rectal cancer. SEARCH METHODS: We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science - Science Citation Index Expanded (1900 to present), four trial registers (ClinicalTrials.gov, ISRCTN registry, the WHO International Clinical Trials Registry Platform, and the National Cancer Institute Clinical Trials database), two thesis and proceedings databases, and relevant scientific societies' publications in February 2022. We performed handsearching and reference checking and contacted study authors of ongoing trials to identify additional studies. SELECTION CRITERIA: We searched for randomized controlled trials (RCTs) in people with stage I rectal cancer comparing any modern LE techniques to any RR techniques with or without the use of neo/adjuvant chemoradiotherapy (CRT). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. We calculated hazard ratios (HR) and standard errors for time-to-event data and risk ratios for dichotomous outcomes, using generic inverse variance and random-effects methods. We regrouped surgical complications from the included studies into major and minor according to the standard Clavien-Dindo classification. We assessed the certainty of evidence using the GRADE framework. MAIN RESULTS: Four RCTs were included in data synthesis with a combined total of 266 participants with stage I rectal cancer (T1-2N0M0), if not stated otherwise. Surgery was performed in university hospital settings. The mean age of participants was above 60, and median follow-up ranged from 17.5 months to 9.6 years. Regarding the use of co-interventions, one study used neoadjuvant CRT in all participants (T2 cancers); one study used short-course radiotherapy in the LE group (T1-T2 cancers); one study used adjuvant CRT selectively in high-risk patients undergoing RR (T1-T2 cancers); and the fourth study did not use any CRT (T1 cancers). We assessed the overall risk of bias as high for oncologic and morbidity outcomes across studies. All studies had at least one key domain with a high risk of bias. None of the studies reported separate outcomes for T1 versus T2 or for high-risk features. Low-certainty evidence suggests that RR may result in an improvement in disease-free survival compared to LE (3 trials, 212 participants; HR 1.96, 95% confidence interval (CI) 0.91 to 4.24). This would translate into a three-year disease-recurrence risk of 27% (95% CI 14 to 50%) versus 15% after LE and RR, respectively. Regarding sphincter function, only one study provided objective results and reported short-term deterioration in stool frequency, flatulence, incontinence, abdominal pain, and embarrassment about bowel function in the RR group. At three years, the LE group had superiority in overall stool frequency, embarrassment about bowel function, and diarrhea. Local excision may have little to no effect on cancer-related survival compared to RR (3 trials, 207 participants; HR 1.42, 95% CI 0.60 to 3.33; very low-certainty evidence). We did not pool studies for local recurrence, but the included studies individually reported comparable local recurrence rates for LE and RR (low-certainty evidence). It is unclear if the risk of major postoperative complications may be lower with LE compared with RR (risk ratio 0.53, 95% CI 0.22 to 1.28; low-certainty evidence; corresponding to 5.8% (95% CI 2.4% to 14.1%) risk for LE versus 11% for RR). Moderate-certainty evidence shows that the risk of minor postoperative complications is probably lower after LE (risk ratio 0.48, 95% CI 0.27 to 0.85); corresponding to an absolute risk of 14% (95% CI 8% to 26%) for LE compared to 30.1% for RR. One study reported an 11% rate of temporary stoma after LE versus 82% in the RR group. Another study reported a 46% rate of temporary or permanent stomas after RR and none after LE. The evidence is uncertain about the effect of LE compared with RR on quality of life. Only one study reported standard quality of life function, in favor of LE, with a 90% or greater probability of superiority in overall quality of life, role, social, and emotional functions, body image, and health anxiety. Other studies reported a significantly shorter postoperative period to oral intake, bowel movement, and off-bed activities in the LE group. AUTHORS' CONCLUSIONS: Based on low-certainty evidence, LE may decrease disease-free survival in early rectal cancer. Very low-certainty evidence suggests that LE may have little to no effect on cancer-related survival compared to RR for the treatment of stage I rectal cancer. Based on low-certainty evidence, it is unclear if LE may have a lower major complication rate, but probably causes a large reduction in minor complication rate. Limited data based on one study suggest better sphincter function, quality of life, or genitourinary function after LE. Limitations exist with respect to the applicability of these findings. We identified only four eligible studies with a low number of total participants, subjecting the results to imprecision. Risk of bias had a serious impact on the quality of evidence. More RCTs are needed to answer our review question with greater certainty and to compare local and distant metastasis rates. Data on important patient outcomes such as sphincter function and quality of life are very limited. Results of currently ongoing trials will likely impact the results of this review. Future trials should accurately report and compare outcomes according to the stage and high-risk features of rectal tumors, and evaluate quality of life, sphincter, and genitourinary outcomes. The role of neoadjuvant or adjuvant therapy as an emerging co-intervention for improving oncologic outcomes after LE needs to be further defined.

A comparison of perineal stapled prolapse resection and the Altemeier procedure at 2 Canadian academic hospitals.

BACKGROUND: The preferred perineal repair method for full-thickness rectal prolapse is the Altemeier procedure, a perineal proctosigmoidectomy with handsewn anastomosis. A recently described variant of this procedure combines the resection and anastomosis into 1 step by means of linear and transverse stapling. There are few published data comparing the characteristics and outcomes of these 2 approaches. METHODS: This retrospective review, performed at 2 Canadian academic hospitals, compares surgical and cost outcomes between the perineal stapled prolapse resection (PSPR) and the Altemeier procedure. All patients who underwent these procedures between 2015 and 2019 were included. RESULTS: There were 25 patients in the PSPR group and 19 in the Altemeier group. Patients in the PSPR group were significantly older than those in the Altemeier group (81 [95% confidence interval (CI) 70-92] yr v. 74 [95% CI 63-85] yr; p = 0.047), had a lower body mass index (21.4 [95% CI 17.7-25.1] v. 24.4 [95% CI 18.5-30.3]; p = 0.042) and had equivalent American Society of Anesthesiologists scores (2.84 [95% CI 2.09-3.59] v. 2.68 [95% CI 1.93-3.43]; p = 0.49). The operative time for PSPR was significantly less (30.3 [95% CI 16.3-44.3] min v. 67 [95% CI 43-91] min; p < 0.001), as were the operative costs. Recurrence (28.0% v. 36.8%; p = 0.53) and complication rates were equivalent. CONCLUSION: PSPR is a safe, efficient and effective approach to perineal proctosigmoidectomy. It is associated with surgical outcomes comparable to those of the Altemeier procedure, but with a significant reduction in operative time and cost.

Oncologic Outcomes Associated With MRI-detected Extramural Venous Invasion (mrEMVI) in Rectal Cancer: A Systematic Review and Meta-analysis.

BACKGROUND: The role of MRI-detected EMVI (mrEMVI) as a reliable prognostic factor in rectal cancer has been emphasized in recent years but this finding remains underreported by many institutions. OBJECTIVE: This review aimed to demonstrate the importance of pre- and post-treatment MRI-detected EMVI as independent prognostic factors of adverse oncologic outcomes in patients undergoing neoadjuvant therapy followed by total mesorectal excision. METHODS: This review was designed using the PRISMA guidelines. The following electronic databases were searched from January 2002 to January 2020: CENTRAL, Ovid MEDLINE, PubMed, and Ovid Embase. Main outcomes included DFS and overall survival (OS). Other outcomes of interest comprised positive resection margin and synchronous metastases. RESULTS: Seventeen studies involving a total of 3821 patients were included for data synthesis. For preneoadjuvant treatment mrEMVI, pooled hazard ratio (HR) estimate for DFS was 2.30 (95% confidence intervals (CI) 1.54-3.44) for higher recurrence in mrEMVI-positive patients. mrEMVI-positive patients were found to have a lower OS with a pooled HR of 1.68 (95%CI 1.27-2.22). Pooled risk ratio for synchronous metastasis was 4.11 (95%CI 2.80-6.02) for mrEMVI-positivity. For postneoadjuvant treatment EMVI (ymrEMVI), positive status showed a lower DFS with a pooled HR of 2.04 (95%CI 1.55-2.69). Risk ratio of having a positive resection margin status was 2.95 (95%CI 1.75-4.98) for ymrEMVI-positive patients. CONCLUSIONS: This review showed that oncologic outcomes are significantly worse for both pre- and post-neoadjuvant treatment mrEMVI-positive patients. MRI-detected EMVI should be consistently reported in rectal cancer staging and may provide guidance for the targeted use of additional systemic therapy.

Prophylactic tamsulosin and urinary retention rates following elective colorectal surgery: a retrospective cohort study.

PURPOSE: Postoperative urinary retention (POUR) is a known morbidity after colorectal surgery. This study investigated the effect of prophylactic tamsulosin on urinary retention rates after colorectal surgery. METHODS: A retrospective cohort study of male patients 50 years or older undergoing elective colonic and rectal resections from May 2014 to November 2019 was performed. The intervention assessed was prophylactic tamsulosin use. POUR, defined by requiring intermittent or reinsertion of urinary catheter, was compared using chi-squared analysis. RESULTS: A total of 332 patients were included, 131 received no tamsulosin, and 201 received prophylactic tamsulosin. Overall POUR was significantly reduced (16.8% vs. 9.5%, p = 0.047). Subgroup analysis for age 50-59 revealed no difference (9.1% vs. 9.4%, p = 0.96), but POUR risk was significantly lower in age 60 and older (20.7% vs. 9.5%, p = 0.02). No significant difference was found in rectal resections alone (18.2% vs. 13.2%, p = 0.34). CONCLUSION: Prophylactic tamsulosin reduced POUR after colorectal surgery with the greatest effect in men 60 years or older and colonic resections.

Effectiveness of a rectal cancer education video on patient expectations.

AIM: Discrepancy between patient expectations and outcomes can negatively affect patient satisfaction and quality of life. We aimed to assess patient expectations of bowel, urinary, and sexual function after rectal cancer treatments, and whether a preoperative education video changed expectations. METHODS: A total of 45 patients were assessed between January 2018 and January 2021 in a tertiary care hospital in Vancouver, Canada. Patients included were rectal cancer patients who had neoadjuvant chemoradiation and were listed for low anterior resection but had not yet had surgery. Following surgical consultation but before surgery, a questionnaire assessing expectations of lifestyle after treatments was administered. Patients then watched an educational video and repeated the questionnaire to assess for changes in expectations. RESULTS: Patient scores indicated expectation that control of bowel movements, urination, and sexual function would sometimes be problematic, but had a range from occasionally problematic to good function. Significant change after the video was seen in the expectation of needing medications for bowel control, and 44%-69% of individual patient answers changed from prevideo to post-video, depending on the question. The education video was scored as helpful or very helpful by 82% of patients. CONCLUSIONS: Patients have varying expectations of problematic control of bowel, urinary, and sexual function following rectal cancer treatments. A pretreatment education video resulted in a trend toward changed expectations for functional outcomes in most patients. Further educational modalities for patients may provide more uniform expectations of function and increase patient satisfaction after rectal cancer treatments.

Long-term outcomes after seton placement for perianal fistulas with and without Crohn's disease.

AIM: Perianal sepsis in Crohn's disease (CD) fistulas is managed with antibiotics and surgical drainage; a noncutting seton is used for an identified transsphincteric fistula tract. The optimal management following seton placement for initial control of perianal sepsis remains to be determined. Our main aim was to assess the success rates of curative surgery, seton removal or long-term indwelling seton in patients with and without CD. METHOD: This was a retrospective cohort of consecutive patients with a perianal fistula treated with a noncutting seton between 2010 and 2019, including 83 CD patients and 94 patients without CD. Initial control of symptomatic perianal infection with a seton and subsequent healing and reintervention rates were compared between the three postseton management strategies. RESULTS: A total of 177 patients, 61% male and 83.1% with complex fistulas, were followed for a median of 23 months (interquartile range 11-40 months). Immunomodulatory treatment was used in 90.4% of CD patients after seton placement. Good initial control of perianal infection was achieved with a seton in CD and non-CD patients, at 92.9% and 96.7%, respectively (p = 0.11). Overall fistula healing or control for CD and non-CD patients was, respectively, 64% and 86% (p = 0.1) after curative surgery, 49% and 71% after seton removal (p = 0.21) and 58% and 50% with long-term seton placement (p = 0.72). Overall reintervention for recurrence was 83% in CD versus 53.1% in non-CD patients during the follow-up period (p = 0.002). CONCLUSION: Definitive surgery was possible in only a minority of CD patients. Long-term seton management was an effective option in patients with CD with acceptable improvement and recurrence rates.

Colorectal surgery surgical site infection prevention practices in British Columbia.

Surgical site infections (SSI) pose significant morbidity after colorectal surgery. We sought to document current practices in colorectal surgery SSI prevention in British Columbia (BC). Reporting the current provincial landscape on SSI prevention helps to understand the foundation upon which improvements can take place. We surveyed all BC surgeons performing elective colon and rectal resections, and 97 surveys were completed (60% response rate). Eighty-six per cent of respondent hospitals tracked SSI rates. The reported superficial SSI was less than 5% and the anastomotic leak/organ space rate was less than 10%. All respondents gave preoperative prophylactic antibiotics, with 24% continuing antibiotics postoperatively; 62% are using oral antibiotics (OAB) and mechanical bowel preparation (MBP) and 29% use MBP without OAB. Areas for improvement include OAB with MBP and discontinuing prophylactic antibiotics postoperatively, as recommended by the World Health Organization.

Predictors of rectal adenoma recurrence following transanal endoscopic surgery: a retrospective cohort study.

BACKGROUND: Transanal endoscopic surgery is the treatment of choice in patients with rectal adenomas that cannot be removed by endoscopy. However, the risk of adenoma recurrence and optimal surveillance is not well defined. The objective of this study was to characterize the timing and frequency of rectal adenoma recurrence after removal by transanal endoscopic surgery and identify recurrence risk factors. METHODS: This was a retrospective cohort study of a large, single-center academic institution in Vancouver, BC, Canada. Consecutive patients between May 1, 2007 and September 30, 2016 with pathology-confirmed rectal adenoma treated by primary excision with transanal endoscopic surgery and at least 1 year of confirmed endoscopic follow-up were included. Main outcome measures were recurrence rates following TEM as well as risk factors for recurrence. RESULTS: 297 patients met inclusion criteria. The mean age of patients was 66.5 ± 11.5 years and 57.9% were male. Median follow-up was 623 (range 56-3841) days. A total of 62 recurrences occurred in 41 patients (13.8% of study population). Recurrences were managed with repeat transanal endoscopic surgery or endoscopic resection 67.7% and 25.8% of the time, respectively. Radical resection was required for adenocarcinoma in 4 patients. Recurrence-free survival rates were 93.4% at 1 year, 86.2% at 2 years, and 73.1% at 5 years. After adjusting for individual surgeons, adenoma height, size > 3 cm, high-grade dysplasia, positive margins, and management of the rectal defect, patients who underwent surgery in the latter 5 years of the study had lower odds of recurrence (OR 0.42, 95% CI 0.19, 0.93, p = 0.03). CONCLUSIONS: Rectal adenomas managed by transanal endoscopic surgery are lesions at high risk for recurrence; surveillance should be performed within the first 2 years and continued for a total of at least 5 years. Most recurrences can be successfully treated with repeat TEM or endoscopic resection.

Single-stage repair of contaminated hernias using a novel antibiotic-impregnated biologic porcine submucosa tissue matrix.

BACKGROUND: Single-stage repair of incisional hernias in contaminated fields has a high rate of surgical site infection (30-42%) when biologic grafts are used for repair. In an attempt to decrease this risk, a novel graft incorporating gentamicin into a biologic extracellular matrix derived from porcine small intestine submucosa was developed. METHODS: This prospective, multicenter, single-arm observational study was designed to determine the incidence of surgical site infection following implantation of the device into surgical fields characterized as CDC Class II, III, or IV. RESULTS: Twenty-four patients were enrolled, with 42% contaminated and 25% dirty surgical fields. After 12 months, 5 patients experienced 6 surgical site infections (21%) with infection involving the graft in 2 patients (8%). No grafts were explanted. CONCLUSIONS: The incorporation of gentamicin into a porcine-derived biologic graft can be achieved with no noted gentamicin toxicity and a low rate of device infection for patients undergoing single-stage repair of ventral hernia in contaminated settings. TRIAL REGISTRATION: The study was registered March 27, 2015 at www.clinicaltrials.gov as NCT02401334.

Reducing time from colon cancer surgery to initiation of adjuvant chemotherapy: pilot project.

Summary: Surgical resection followed by adjuvant chemotherapy is the standard of care for patients with stage III colon cancer. To shorten the time interval between surgery and chemotherapy in patients with colon cancer, we instituted a standardized referral pathway. Evaluation of the intervention demonstrated that referring our patients with colon cancer to a medical oncologist earlier in the treatment process increased the number of patients in whom chemotherapy was initiated within 8 weeks compared with historical controls. These results support early medical oncology referral at institutions where delays in adjuvant chemotherapy initiation exist.

Peritoneal perforation during transanal endoscopic microsurgery is not associated with significant short-term complications.

BACKGROUND: In patients treated by transanal endoscopic microsurgery (TEM), breach of the peritoneal cavity is a feared intraoperative challenge. Our aim is to analyze predictors and short-term outcomes of patients with peritoneal perforation (TEM-P) when compared to similar patients with no peritoneal compromise (TEM-N). METHODS: At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for all patients treated by TEM is maintained in a prospectively populated database. A retrospective review was performed and two groups were established for comparison: TEM-P and TEM-N. Statistical analysis was performed using student's t or chi-squared test, where appropriate. RESULTS: Of 619 patients treated by TEM between 2007 and 2016, 39 (6%) patients were in the TEM-P group and 580 (94%) in the TEM-N group. There were no differences between the groups in patient age, gender, histology, or tumor size. Patients who had peritoneal perforations had more proximal lesions (11 vs. 7 cm, p < 0.0001), anterior lesions (56 vs. 43%, p < 0.05), and longer operations (80 vs. 51 min, p < 0.005). While most defects were closed endoluminally, 2 patients with perforation were converted to transabdominal surgery. There was a difference in overall hospital stay with TEM-P patients staying on average 2 days in hospital with fewer patients managed as day surgery (31 vs. 73%, p < 0.0001). There were no mortalities or significant 30-day complications in the TEM-P group and only one patient required readmission. CONCLUSIONS: The St. Paul's Hospital TEM experience suggests patients with peritoneal breach during TEM can be safely managed with outcomes similar to patients without peritoneal entry. Proximal, anterior lesions are at highest risk of peritoneal perforation.

Assessing the safety and outcomes of repeat transanal endoscopic microsurgery.

BACKGROUND: Transanal endoscopic microsurgery (TEM) is the treatment of choice for benign rectal tumors and select early rectal cancers. This surgical approach has become ubiquitous and surgeons are seeing recurrent lesions after TEM resection. This study aims to outline the safety and outcomes of repeat TEM when compared to primary TEM procedures. METHODS: At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for patients treated by TEM are maintained in a prospectively populated database. Two groups were established for comparison: patients undergoing first TEM procedure (TEM-P) and patients undergoing repeat TEM procedure (TEM-R). RESULTS: Between 2007 and 2017, 669 patients had their first TEM procedure. Over this time frame, 57 of these patients required repeat TEM procedures, including 15 of these patients treated by 3 or more TEMs. Indications for repeat TEM included recurrence (78%), positive margins (15%), and metachronous lesions (7%). There were no differences between the groups in patient age, gender, or tumor histology. Compared to TEM-P, TEM-R had shorter operative times (38 vs. 52 min, p < 0.001), more distal lesions (5 vs. 7 cm, p < 0.004), and smaller lesions (3 vs. 4 cm, p < 0.0003). The TEM-R group had similar length of hospital stay (0.45 vs. 0.56 days, p = 0.65), rates of clear margins on pathology (81% vs. 88%, p = 0.09), and 30-day readmission rates (7% vs. 4%, p = 0.27) when compared to TEM-P group. TEM-R was more likely to be managed without suturing the surgical defect (72% vs. 32%, p < 0.0001). Repeat TEM was associated with similar post-operative complications as primary TEM graded on the Clavien-Dindo classification scale (Grade 1: 5% vs. 5%, Grade 2: 5% vs. 4%, Grade 3: 5% vs. 1%, p = 0.53). No 30-day mortality occurred in either group. CONCLUSIONS: The St. Paul's Hospital TEM experience suggests repeat TEM is a safe and feasible procedure with similar outcomes as patients undergoing first TEM.

The surgical defect after transanal endoscopic microsurgery: open versus closed management.

BACKGROUND: To determine whether closure of the defect created during full thickness excision of a rectal lesion with transanal endoscopic microsurgery (TEM) leads to fewer complications when compared to leaving the defect unsutured. METHODS: This is a single-center cohort study using a prospectively maintained database. All patients ≥18 years old treated with full thickness TEM with no compromise of the peritoneal cavity were included. Two cohorts were established: patients with the defect sutured and patients with the defect left open. Demographic, operative, and pathologic data were compared. The main outcome analyzed was early (<30 day postoperative) complications, including bleeding that required investigation and readmission, infection, and reoperation. RESULTS: Between 2007 and 2014, data for all patients treated with TEM have been maintained in the St. Paul's Hospital TEM database. Overall, 236 patients had the TEM defect sutured (TEM-S) and 105 patients had the defect left open (TEM-O). There were no differences between the groups in patient age, gender, tumor size or underlying tumor histology. There was no difference in OR time between the groups, but the most experienced TEM surgeon performed significantly more of the TEM-S procedures (61 vs. 39 %, p < 0.01). There were 40 postoperative complications, affecting 11.7 % of the cohort. The complication rate was higher in the TEM-O group (8.4 vs. 19.0 %, p = 0.03). There was no statistically significant difference in bleeding complications (4.7 vs. 7.6 %, p = 0.27) or infections (2.1 vs. 6.7 %, p = 0.05). Readmissions were less common in the TEM-S group (4.7 vs 12.4 %, p = 0.01). CONCLUSION: The St. Paul's Hospital TEM experience suggests that while it is safe to leave rectal defects open when a robust mesorectal fat layer is present, there appears to be fewer postoperative complications when the defect is sutured closed.

Surgical Site Infection Rates Following Implementation of a Colorectal Closure Bundle in Elective Colorectal Surgeries.

BACKGROUND: Surgical site infections of up to 27% are reported for colorectal surgery. Care bundles have been introduced to decrease surgical site infection rates, but are variable in composition. OBJECTIVE: This study aimed to determine whether the addition of a "Colorectal Closure Bundle" in our Enhanced Recovery After Surgery pathway decreased surgical site infection rates. DESIGN: This is a retrospective study of elective colon resections before and after the addition of a closure bundle. SETTINGS: This study was conducted at a single academic institution. PATIENTS: Patients undergoing consecutive elective colon resections with primary anastomosis, December 2012 to July 31, 2014, enrolled in our Enhanced Recovery After Surgery pathway. Exclusion criteria were stoma creation and closure and preoperative chemoradiation. INTERVENTION: The "Colorectal Closure Bundle," which includes a change in gown and gloves, redraping, wound lavage, and a new set of instruments for closure, was added to the Enhanced Recovery After Surgery pathway. MAIN OUTCOME MEASURE: The primary outcome measured was surgical site infections as defined by CDC criteria. RESULTS: Two hundred five patients were reviewed, 111 preintervention and 94 postintervention. Overall surgical site infection rates were 25.2% preintervention vs 26.6% postintervention (p = 0.82). Surgical site infections were subdivided into "superficial" and "deep and organ space" and were 14.4% and 10.8% preintervention vs 14.9% and 11.7% postintervention (p = not significant). Smoking and diabetes mellitus were found to be independently associated with surgical site infections on multivariate analysis, with adjusted odds ratios of 4.32 (95% CI, 1.70-10.94), p = 0.002, and 2.87 (95% CI 1.30-6.34), p = 0.009. LIMITATIONS: Limitations include the retrospective nature of the study and the small sample size. CONCLUSIONS: There was no change in surgical site infection rates after implementation of the "Colorectal Closure Bundle." Smoking and diabetes mellitus were the only significant risk factors associated with increased surgical site infections. Our infection rates remain high and further change in our perioperative protocol is needed.

Infliximab in ulcerative colitis: the impact of preoperative treatment on rates of colectomy and prescribing practices in the province of British Columbia, Canada.

BACKGROUND: Approximately 20% of patients with ulcerative colitis will require surgical treatment. Recent data suggest that infliximab may reduce the need for surgery in patients with severe ulcerative colitis. However, it is unclear whether data from these small trials will translate to reduced colectomy rates in populations with ulcerative colitis. OBJECTIVE: The purpose of this study was to determine the impact of infliximab on the rates of colectomy for ulcerative colitis and the prescribing practices for infliximab in British Columbia, Canada. DESIGN: We retrospectively reviewed data from 4 province-wide population-based databases maintained by the British Columbia Ministry of Health, a central registry, a hospital separations file, a physician payment file, and a pharmaceutical file. Data were collected from April 1, 2001, to March 31, 2010. SETTINGS: This investigation was conducted at the University of British Columbia. PATIENTS: All patients aged 18 to 75 with ulcerative colitis were included and identified using a validated strategy with International Classification of Diseases 9/10 codes. Patients with severe ulcerative colitis were defined by treatment with a course of corticosteroids during the study period. Patients treated with infliximab were identified using the provincial pharmaceutical file. MAIN OUTCOME MEASURES: The primary outcome was surgery determined by an International Classification of Diseases 9/10 code for partial or total colectomy. RESULTS: Between 2001 and 2010, 7227 subjects were identified with ulcerative colitis. The number of subjects with severe ulcerative colitis was 2537. For general ulcerative colitis, rates of colectomy decreased from 9.97% to 8.88% in the preinfliximab era (2003-2004) and postinfliximab era (2008-2009; p = 0.03). For severe ulcerative colitis, there was no significant difference in colectomy rates (9.97% vs 11.14%; p = 0.18). The highest rate of infliximab prescription was found to be in the provincial health region that encompasses the tertiary academic centers of the province. LIMITATIONS: Although the overall number of patients in this analysis is sizeable, the number of patients who were prescribed infliximab during the study period is relatively modest, which may have impacted trends. CONCLUSIONS: In the severe ulcerative colitis population, there has been no change in the colectomy rate over time despite the introduction of infliximab.

Transanal endoscopic microsurgery: a review.

Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.

Les adénomes et les cancers du rectum sont fréquents. Il est possible de procéder à l'exérèse des petits adénomes par voie coloscopique, tandis que la résection des polypes plus volumineux se fera par exérèse trans-anale classique. En raison de difficultés d'ordre technique, les adénomes des portions moyenne et supérieure du rectum nécessitent une résection radicale. La microchirurgie endoscopique trans-anale (MCET) a d'abord été conçue comme une solution de rechange pour le traitement de ces lésions. Toutefois, depuis son avènement, la MCET a également été utilisée pour diverses lésions rectales, dont les carcinoïdes, les prolapsus et diverticules rectaux, les carcinomes au stade précoce et la résection palliative des cancers rectaux. L'objectif de la présente revue est de décrire la situation actuelle de la MCET pour ce qui est du traitement des lésions rectales. Depuis les années 1980, la MCET a connu des progrès substantiels. Compte tenu du faible taux de récurrences qui l'accompagne, il s'agit de la méthode de choix pour la résection des adénomes dont l'exérèse endoscopique est impossible. Certaines études ont montré les avantages de son utilisation pour le traitement des cancers rectaux précoces de stade T1, comparativement à la chirurgie radicale chez certains patients. Toutefois, pour les cancers rectaux plus avancés, la MCET doit être considé rée comme une mesure palliative ou expérimentale. Cette technique s'est aussi révélée sécuritaire pour le traitement d'autres tumeurs rectales rares, comme les carcinoïdes. La MCET pourrait ouvrir la voie à de nouvelles stratégies pour le traitement des pathologies du rectum, là où les limites des techniques trans-anales offrent peu d'innovations en termes de chirurgie endoluminale.