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This systematic review aimed to assess the effects of upper gastrointestinal (UGI) dysmotility on outcomes of surgical treatment of colonic inertia (CI). This PRISMA-compliant systematic review and meta-analysis searched PubMed, Scopus, Google Scholar, and clinicaltrials.gov through October 2023 for studies that assessed outcomes of CI patients who underwent colectomy while putting data on UGI motility in context. The primary outcome was postoperative persistence or recurrence of constipation. Secondary outcomes were postoperative complications, continence, and quality of life (QoL) improvements. The revised tool to assess the risk of bias in nonrandomized studies of interventions was used to assess the risk of bias, and the certainty of evidence was graded using the GRADE approach. Eight studies (1991 to 2013) included data on UGI evaluation of CI patients; 12.8 to 24.3% were tested for concomitant GI dysmotility. High rates of motility abnormalities were in the small bowel (31.4%), stomach (34.1%), and esophagus (48.5%). Patients with UGI dysmotility and CI were more likely to experience constipation recurrence (OR: 10.71, 95% CI: 2.17; 52.87, P =0.004) and less likely to have postoperative QoL improvements (OR: 0.16, 95% CI: 0.04; 0.65, P =0.010) compared with patients with CI and no abnormal UGI testing. There were no differences in postoperative complications (OR: 1.59, 95% CI: 0.64; 4.267, P =0.542) or continence (OR: 0.29, 95% CI: 0.06; 1.47, P =0.0136) rates. Large subsets of CI patients with concomitant UGI dysmotility may be preoperatively underdiagnosed. UGI dysmotility may be associated with a higher risk of postoperative recurrence of constipation and suboptimal improvements in QoL. We recommend routine UGI evaluation before surgery for CI., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Rectal cancer surgery is technically demanding, especially in males. Robotic assistance may help overcome these challenges. This study aimed to identify factors associated with robotic-assisted proctectomy in rectal cancer., Methods: Retrospective case-control analysis of patients with clinical stage I-III rectal adenocarcinoma who underwent proctectomy from the National Cancer Database (2010-2019) was conducted. Univariable and multivariable binary logistic regression analyses were conducted to determine predictive factors of robotic-assisted proctectomy in rectal cancer., Results: 67 145 patients (60.9% male; mean age: 61.15 ± 12.49 years) were included. 44.7% had stage III disease and 66.2% received neoadjuvant radiation. The surgical approach was laparotomy (n = 29 725), laparoscopy (n = 21 657), and robotic-assisted proctectomy (n = 15 763). Independent predictors for the use of robotic-assisted proctectomy were age <50 years (OR: 1.06; P = .032), male sex (OR: 1.07, P < .001), Asian race (OR: 1.25; P < .001), private insurance (OR: 1.25; P < .001), rectal cancer treatment between 2015 and 2019 (OR: 3.52; P < .001), stage III disease (OR: 1.06; P = .048), neoadjuvant radiation (OR: 1.26; P < .001), and pull-through coloanal anastomosis (OR: 1.15; P < .001). Robotic-assisted surgery was less often used in Black (OR: .857, P < .001) and American Indian patients (OR: .62, P = .002) and those with a Charlson score = 3 (OR: .818, P = .002), living in rural areas (OR: .865, P = .033), who were uninsured (OR: .611, P < .001), and undergoing pelvic exenteration (OR: .461, P < .001)., Conclusions: Demographic and insurance disparities of robotic-assisted proctectomy are Black and American Indian patients and those with higher Charlson comorbidity index scores and uninsured patients were less likely to undergo robotic-assisted proctectomy. While patients with advanced disease and/or received neoadjuvant radiation were more likely to undergo robotic-assisted proctectomy, robotic-assisted surgery was less often performed in pelvic exenteration., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: None of the authors reports any relevant financial disclosures. Dr Wexner is a consultant for Baxter, Becton, Dickinson and Co, Glaxo Smith Kline, Intuitive Surgical, Livsmed, Medtronic, OstomyCure, Stryker, Takeda, and Virtual Ports; is a member of the Data Safety Monitoring Board of JSR/WCG/ACI (chair), Polypoid (chair), and Boomerang; and receives royalties from Intuitive Surgical, Karl Storz Endoscopy America Inc, and Unique Surgical Solutions, LLC. Dr Emile is a consultant for Becton, Dickinson and Company.

Background: Ileus is a common complication of major abdominal surgery, including colorectal resection. The present study aimed to assess the predictors of ileus after laparoscopic right colectomy for colon cancer., Methods: This study was a retrospective case-control analysis of a prospective IRB-approved database of patients who underwent laparoscopic right colectomy at the Department of Colorectal Surgery, Cleveland Clinic Florida. Patients who developed ileus after right colectomy were compared to patients without ileus to determine the risk factors of ileus., Results: The present study included 270 patients with a mean age of 68.7 years. Thirty-six patients (13.3%) experienced ileus after laparoscopic right colectomy. The median duration of ileus was 6 days. Factors associated with ileus were age (71.6 vs 68.2 years, P = .158), emergency colectomy (11.1% vs 3.9%, P = .082), extended hemicolectomy (19.4% vs 6.8%, P = .021), green gastrointestinal anastomosis (GIA) 4.8mm staple height cartridge (19% vs 8.1%, P = .114), and longer operative time (177.9 vs 160.4 minutes, P = .157). The only independent predictor of ileus was extended colectomy (OR: 16.7, P = .003)., Conclusions: Increased age, emergency surgery, green GIA cartridge, and longer operative times were associated with ileus, yet the only independent predictor of ileus was extended right hemicolectomy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: None of the authors reports any relevant financial conflicts of interest. Dr. Wexner is a consultant for Baxter, Becton, Dickinson and Co, Glaxo Smith Kline, Intuitive Surgical, Livsmed, Medtronic, OstomyCure, Stryker, Takeda, and Virtual Ports, is a member of the Data Safety Monitoring Board of JSR/WCG/ACI (chair), Polypoid (chair), and Boomerang, and receives royalties from Intuitive Surgical, Karl Storz Endoscopy America Inc., and Unique Surgical Solutions, LLC.

Aim: Anastomotic stricture occurs in up to 30% of colorectal resections; however, evidence on risk factors and preventive measures remains scarce. This study aimed to identify technical factors responsible for increasing the risk for colorectal and coloanal anastomotic strictures., Method: This was a retrospective cohort study of patients with anastomotic stricture who underwent resection and/or redo anastomosis between January 1, 2011 and August 1, 2021 in a tertiary referral centre. Patients with anastomotic stricture were compared with an equal number of randomly selected patients without anastomotic complications, who were operated on during the same time period. The main outcome measures were technical risk factors of anastomotic stricture., Results: Each group included 50 patients who were similar for age, sex, American Society of Anesthesiologists score, distance of anastomosis to the dentate line and indication for surgery. Median follow-up was significantly longer in the non-stricture group (38.6 months vs. 12.6 months, p = 0.04). Splenic flexure mobilization [hazard ratio (HR) = 0.18 [2], 95% CI: 0.08-0.39, p < 0.001], high ligation of the inferior mesenteric artery (HR = 0.22, 95% CI: 0.09-0.5, p < 0.001) and high ligation of the inferior mesenteric vein (HR = 0.21, 95% CI: 0.09-0.50, p < 0.001) were associated with a lower likelihood of anastomotic stricture. Conversely, use of a 25-mm-diameter circular stapler (HR = 22.69, 95% CI: 2.69-191.10, p < 0.001), clinically significant anastomotic leak (HR = 3.94, 95% CI: 2.04-7.64, p < 0.001), firing the stapler more than once for rectal division (HR = 24.75, 95% CI: 6.85-89.38, p < 0.001) and diverting stoma (HR = 3.087, 95% CI: 1.736-5.491, p < 0.0001) were predictive of an anastomotic stricture., Conclusion: Failure to mobilize the splenic flexure and to perform high ligation of the inferior mesenteric vessels were associated with higher odds of anastomotic stricture. A small-diameter circular stapler and multiple distal stapler firings were also associated with anastomotic stricture. These data support routine splenic flexure ligation and high ligation of the inferior mesenteric vessels as well as avoidance of both multiple  stapler firings for rectal transection and a 25-mm circular stapler for anastomosis., (© 2024 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: This study aimed to investigate factors associated with prolonged operative time in laparoscopic right hemicolectomy for colon cancer., Methods: This was a retrospective review of patients with colon cancer who underwent laparoscopic right hemicolectomy between 2011 and 2021. Linear and binary logistic regression analyses were performed to determine factors associated with prolonged operative time. The association between longer operative times and complications and hospital stay was assessed., Results: One hundred and ninety-seven patients (52.3% female; mean age: 68.8 ± 14.1 years) were included. Factors independently associated with operative time were male sex (β = 17.3, 95% CI: 2, 32.5; p = 0.026) and extended hemicolectomy (β = 67.7, 95% CI: 27.6, 107.9; p = 0.001). American Society of Anesthesiologists (ASA) IV classification had a borderline significant association with operative time (β = 100.4, 95% CI: -2.05, 202.9; p = 0.055). Male sex (r = 0.158; p = 0.026), body mass index (r = 0.205; p = 0.004), ASA classification (r = 0.232; p = 0.001), extended hemicolectomy (r = 0.256; p < 0.001), and intracorporeal vessel control (r = 0.161; p = 0.025) had significant positive correlation with operative times. Patients with operative times ≥ 160 min had significantly longer hospital stays (5 vs. 4 days; p = 0.043) and similar complication rates to patients with shorter operative times., Conclusions: Male sex, advanced ASA classification, and extended hemicolectomy were independently and significantly associated with longer operative times in laparoscopic right hemicolectomy. Longer operative times were associated with longer hospital stays and similar complication rates., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Background: Laparoscopic right hemicolectomy can be technically challenging in patients with increased body mass index, reportedly associated with higher surgical site infection (SSI) and incisional hernia rates. We aimed to assess the association between increased body mass index and short-term outcomes of laparoscopic right hemicolectomy., Methods: This retrospective cohort study included patients with colon cancer who underwent laparoscopic right hemicolectomy between 2011 and 2021. Patients were managed with a standardized care protocol that comprised preoperative, intraoperative, and postoperative measures and were divided according to body mass index-normal body mass index (18-24.9 kg/m 2 ), overweight (25-29.9 kg/m 2) , and obesity (≥30 kg/m 2 ). Body mass index groups were compared for baseline characteristics and outcomes. The main outcome measures were operative time, hospital stay, 30-day complications, reoperation, number of harvested lymph nodes, and resection status., Results: A total of 270 patients (50% male sex; mean age: 68.7 ± 13.5 years) were included-28.5% had normal body mass index, 47% were overweight, and 24.5% had obesity. Mean operative times in obese and overweight patients were significantly longer than patients with normal body mass index (172.1 and 168.8 versus 143.3 minutes, P = .01). Compared to normal body mass index, obesity was associated with significantly higher odds of incisional SSI (odds ratio: 9.29, P = .039). Body mass index had a significant positive correlation with operation time (r = 0.205, P = .004) and incisional SSI (r = 0.126, P = .04). Body mass index groups had similar hospital stays, 30-day complications and mortality, anastomotic leak, ileus, and reoperation., Conclusion: Patients with increased body mass index had longer operative times and higher SSI rates, yet similar hospital stays and comparable 30-day complication rates, mortality, and reoperation to patients with normal body mass index., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Aim: Staplers used in ileocolic anastomosis construction differ in length and height. We assessed the impact of stapler type in creating ileocolic anastomoses on postoperative outcomes., Methods: This retrospective cohort study of an Institutional Review Board approved database included patients who underwent laparoscopic right colectomy for cancer between January 2011 and August 2021. All patients had construction of extracorporeal antiperistaltic stapled ileocolic anastomosis using a linear cutting stapler. Main outcome measures were short-term (<30 day) morbidity and mortality., Results: In all, 270 patients (136 men; median age 70.2 years) were included. A 75 mm stapler was used in 49 (18.1%) patients, 80 mm in 97 (35.9%) and 100 mm in 124 (45.9%). Blue cartridge (stapler height 3.5 mm) was used in 175 (64.5%) and green cartridge (4.8 mm) in 18 (7%) patients; this information was unavailable in 77 (28.5%) cases. Apical enterotomy closure was performed by linear stapler in 54% and linear cutting stapler in 46%. Apical staple line reinforcement or imbrication suturing was used in 26.3%. The overall postoperative complication rate was 28.9%. The anastomotic leak rate was 2.6%. Independent predictors of complications after laparoscopic right colectomy were older age (OR 1.03, 95%CI 1-1.06; P = 0.01), extended colectomy (OR 2.76, 95%CI 1.07-7.08; P = 0.035) and emergency surgery (OR 4.5, 95%CI 1.3-14.9; P = 0.014). A 100-mm linear cutting stapler was an independent protective factor against postoperative complications (OR 0.3, 95%CI 0.18-0.85; P = 0.019). Stapler height and closure technique of apical enterotomy did not affect postoperative complications., Conclusion: Independent predictors of complications after laparoscopic right colectomy were older age, extended colectomy and emergency surgery. Using a 100 mm stapler was an independent protective factor against postoperative complications., (© 2023 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

The increased risk of colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) has been well documented in the literature. The present study aimed to assess the characteristics and outcomes of rectal cancer in patients with IBD. This study was a retrospective review of a prospectively maintained IRB-approved database at Cleveland Clinic Florida. Rectal cancer patients with or without IBD treated with curative surgery between 2016 and 2020 were compared for demographics, disease characteristics, and pathologic and oncologic outcomes. The primary outcomes were 3-year overall survival (OS) and disease-free survival (DFS). Secondary outcomes were clinicopathologic outcomes including disease stage, tumor histology and histologic features, and treatments received. 238 patients with rectal cancer were included, 15 (6.3%) of whom had IBD. IBD patients were significantly younger (52.9 vs 60.3 years, p = 0.033), presented more often with cT1-2 tumors (64.3% vs 30.4%, p = 0.008), and signet-ring cell pathology (14.3% vs 2%, p = 0.02). IBD patients received neoadjuvant chemoradiation less often (40% vs 72.6%, p = 0.029) and had shorter time between diagnosis and surgery (7.5 vs 25 weeks, p = 0.013) than did non-IBD patients. Both groups had similar OS (36 vs 34.7 months, p = 0.431) and DFS (36 vs 32.9 months, p = 0.121). IBD patients with rectal cancer tend to present at a younger age, with a less invasive disease, and signet-ring carcinomas, and receive neoadjuvant treatment less often than non-IBD patients. Based on low level of evidence, IBD and non-IBD rectal cancer patients might have similar survival., (© 2023. Italian Society of Surgery (SIC).)

Introduction: We assessed the association between increased body mass index (BMI) and rectal cancer outcomes., Methods: We included patients who underwent surgery for stage I-III rectal adenocarcinoma who were divided according to BMI at diagnosis: ideal BMI (18.5-24.9 kg/m2) and increased BMI (≥25 kg/m2). Groups were compared using univariate association analyses relative to baseline characteristics, pathologic outcomes, overall survival (OS), and disease-free survival (DFS). Main outcome measures involved circumferential resection margin (CRM), pathologic TNM stage, total mesorectal incision (TME) grade, OS, and DFS., Results: 243 patients (64.6% male; median age 59 years) with a median BMI of 26.3 kg/m2 were included. 62.1% had BMI ≥25 kg/m2. Increased BMI patients had similar proportions of males (66.9% vs. 60.9%; p = 0.407) and comorbidities (ASA III: 47% vs. 37.4%; p = 0.24) to ideal BMI patients. There were no significant differences in cN1-2 stage (p = 0.279) or positive CRM (p = 0.062) rates. The groups had similar complete/near-complete TME, pathologic TN stage, and survival rates. Pathologic and survival outcomes were also similar with a BMI cutoff of 30., Conclusions: There was a trend toward more nodal involvement in preoperative assessment and less CRM involvement in the final pathology of patients with increased BMI. Complete/near-complete TME and survival rates were comparable between the groups., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Background: We reviewed outcomes following cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with appendiceal or colorectal neoplasms and evaluated key prognostic indicators for treatment., Methods: All patients who underwent cytoreductive surgery/HIPEC for appendiceal and colorectal neoplasms were identified from an IRB-approved database. Patient demographics, operative reports, and postoperative outcomes were reviewed., Results: 110 patients [median age 54.5 (18-79) years, 55% male] were included. Primary tumor location was colorectal (58; 52.7%) and appendiceal (52; 47.3%). 28.2%, .9%, and 12.7% had right, left, and sigmoid tumors, respectively; 11.8% had rectal tumors. 12/13 rectal cancer patients underwent preoperative radiotherapy. Mean Peritoneal Cancer Index was 9.6 ± 7.7; complete cytoreduction was achieved in 90.9%. 53.6% developed postoperative complications. Reoperation, perioperative mortality, and 30-day readmission rates were 1.8%, .09%, and 13.6%, respectively. Recurrence at a median of 11.1 months was 48.2%; overall survival at 1 and 2 years was 84% and 56.8%, respectively; disease-free survival was 60.8% and 33.7%, respectively, at a median follow-up of 16.8 (0-86.8) months. Univariate analysis of preoperative chemotherapy, primary malignancy location, primary tumor perforated or obstructive, postoperative bleeding complication, and pathology of adenocarcinoma, mucinous adenocarcinoma and negative lymph nodes were identified as possible predictive factors of survival. Multivariate logistic regression analysis showed that preoperative chemotherapy ( P < .001), perforated tumor ( P = .003), and postoperative intra-abdominal bleeding ( P < .001) were independent prognostic indicators for survival., Conclusions: Cytoreductive surgery/HIPEC for colorectal and appendiceal neoplasms has low mortality and high completeness of cytoreduction score. Preoperative chemotherapy, primary tumor perforation, and postoperative bleeding are adverse risk factors for survival., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Non-relevant disclosures: Dr. Wexner reports receiving consulting fees from ARC/Corvus, Astellas, Baxter, Becton Dickinson, GI Supply, ICON Language Services, Intuitive Surgical, Leading BioSciences, Livsmed, Medtronic, Olympus Surgical, Stryker, Takeda and receiving royalties from Intuitive Surgical and Karl Storz Endoscopy America Inc.

Introduction: Rectovaginal fistulas (RVFs) account for approximately 40% of anorectal complications from obstetrical trauma. Treatment can be challenging requiring multiple surgical repairs. Interposition of healthy transposed tissue (lotus or Martius flap or gracilis muscle) has been used for recurrent RVF. We aimed to review our experience with gracilis muscle interposition (GMI) for post-partum RVF., Methods: A retrospective analysis of patients who underwent GMI for post-partum RVF from February 1995 to December 2019 was undertaken. Patient demographics, number of prior treatments, comorbidities, tobacco use, postoperative complications, additional procedures, and outcome were assessed. Success was defined as absence of leakage from the repair site after stoma reversal., Results: Six of 119 patients who underwent GMI did so for recurrent post-partum RVF. Median age was 34.2 (28-48) years. All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty. All patients underwent fecal diversion prior to or at initial procedure. Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed. Morbidity was reported in 3 (50%) patients, including wound dehiscence, delayed rectoperineal fistula, and granuloma formation in one each, all managed without surgery. There was no morbidity related to stoma closure., Conclusions: Gracilis muscle interposition is a valuable tool for recurrent post-partum RVF. Our ultimate success rate in this very small series was 100% with a relatively low morbidity rate., Competing Interests: Declaration of Conflicting InterestsNo relevant financial disclosures were reported by any authors. Dr. Wexner reports receiving consulting fees from ARC/Corvus, Astellas, Baxter, Becton Dickinson, GI Supply, ICON Language Services, Intuitive Surgical, Leading BioSciences, Livsmed, Medtronic, Olympus Surgical and Stryker, Takeda and receiving royalties from Intuitive Surgical and Karl Storz Endoscopy America Inc., Dr. Emile reports receiving consulting fees from SafeHeal.

Background: This study aimed to compare intra- and extracorporeal division of the vascular pedicle in laparoscopic right colectomy regarding pathological outcomes, short-term morbidity, and local recurrence and distant metastases., Methods: Retrospective analysis of an IRB-approved database of all patients who underwent laparoscopic right colectomy for cancer between 01/2011 and 08/2021. Main outcome measures were number of harvested lymph nodes, length of resected colon, R1 rate, positive lymph node ratio, short-term post-operative morbidity, local recurrence, and distant metastases., Results: Two-hundred seventy-one consecutive patients (136 males) patients underwent laparoscopic right hemicolectomy for cancer during the study period. Vessel ligation was intracorporeal in 171 (63%) and extracorporeal in 100 patients (37%); groups had similar baseline characteristics except for extent of resection as extended right hemicolectomy was significantly more often performed in the intracorporeal group. When the two groups were matched for the extent of resection (standard versus extended right hemicolectomy), the mean number of harvested lymph nodes (28.61 ± 12.04 versus 25.37 ± 10.06, p = 0.04) and median length of the resected colon [26.00 (IQR: 21.00, 32.00) versus 23.00 (IQR: 19.00, 27.00) cm, p = 0.003] were significantly higher in the intracorporeal than in the extracorporeal group. The intracorporeal group required a significantly longer operative time than did the extracorporeal group (168.94 ± 57.9 vs. 139.7 ± 41.3 mins, p = 0.001). No significant differences were noted between the groups in terms of ileus, hemorrhage, surgical site infection, re-operation rates, recurrence, or distant metastases., Conclusion: Intracorporeal vessel ligation in laparoscopic right hemicolectomy was associated with increased lymph node yield and longer specimens, although requiring longer operative times. Postoperative clinical outcomes were similar to outcomes in the extracorporeal ligation group., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Background: Gracilis muscle interposition (GMI) has been associated with favorable outcomes in treating complex perianal fistulas. Outcomes of GMI may vary according to the fistula etiology, particularly between rectovaginal fistulas in women and rectourethral fistulas (RUF) in men. The aim of this study was to assess the outcome of GMI to treat RUF acquired after prostate cancer treatment., Methods: This retrospective cohort study included male patients treated with GMI for RUF acquired after prostate cancer treatment between January 2000 and December 2018 in the Department of Colorectal Surgery, Cleveland Clinic Florida. The primary outcome was the success of GMI, defined as complete healing of RUF without recurrence. Secondary outcomes were length of hospital stay and postoperative complications., Results: This study included 53 male patients with a median age of 68 (range, 46-85) years. Patients developed RUF after treatment of prostate cancer with radiation (52.8%), surgery (34%), or transurethral resection of the prostate (TURP) (13.2%). Median hospital stay was 5 (IQR, 4-7) days. Twenty (37.7%) patients experienced 25 complications, the most common being wound infection and dehiscence. Primary healing after GMI was achieved in 28 (52.8%) patients. Fifteen additional patients experienced successful healing of RUF after additional procedures, for a total success rate of 81.1%. Median time to complete healing was 8 (range, 4-56) weeks. The only significant factor associated with outcome of GMI was wound dehiscence (p = 0.008)., Conclusions: Although the initial success rate of GMI was approximately 53%, it increased to 81% after additional procedures. Complications after GMI were mostly minor, with wound complications being the most common. Perianal wound dehiscence was significantly associated with failure of healing of RUF after GMI., (© 2023. Springer Nature Switzerland AG.)

Background: Despite the pivotal role of magnetic resonance imaging (MRI) in rectal cancer staging and evaluation, the reliability of restaging MRI after neoadjuvant therapy is still debatable. This study aimed to assess the accuracy of restaging MRI by comparing post-neoadjuvant MRI findings with those of the final pathology., Methods: This study was a retrospective review of the medical records of adult rectal cancer patients who had restaging MRI following neoadjuvant therapy and prior to rectal cancer resection in a NAPRC-certified rectal cancer centre between 2016 and 2021. The study compared findings of preoperative, post-neoadjuvant MRI with final pathology relative to T stage, N stage, tumour size, and circumferential resection margin (CRM) status., Results: A total of 126 patients were included in the study. We found fair concordance (kappa -0.316) for T stage between restaging MRI and pathology report, and slight concordance for N stage and CRM status (kappa -0.11, kappa = 0.089, respectively). Concordance rates were lower for patients following total neoadjuvant treatment (TNT) or with a low rectal tumour. In total, 73% of patients with positive N pathology status had negative N status in the restaging MRI. Sensitivity and specificity regarding positive CRM in post-neoadjuvant treatment MRI were 45.45% and 70.4%, respectively., Conclusion: We found low concordance levels between restaging MRI and pathology regarding TN stage and CRM status. Concordance levels were even lower for patients after TNT regimen and with a low rectal tumour. In the era of TNT and watch-and-wait approach, we should not rely solely on restaging MRI to make post-neoadjuvant treatment decisions., (© 2023 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: Total mesorectal excision is the standard surgical procedure for rectal cancer treatment. Several studies have shown a close correlation between the prognosis of patients with rectal cancer and the completeness of the mesorectal specimen., Objective: To assess the correlation between macroscopic assessment of mesorectal excision and long-term oncological outcomes., Design: Retrospective analysis of an Institutional Review Board-approved database., Settings: Tertiary referral center., Patients: Patients with rectal cancer who were operated on between March 2016 and October 2019 were classified into 3 groups based on the mesorectal specimen quality: complete, near complete, and incomplete. Only patients with a follow-up of ≥2 years and without signs of preoperative distant disease were included., Main Outcome Measures: Relationship between total mesorectal excision and local and distant recurrence rates in patients with rectal cancer., Results: A total of 124 patients (35.5% females) were included in the analysis, with a mean age of 58.1 (SD 12) years and a mean BMI of 26.4 (SD 4.59) kg/m². Neoadjuvant chemoradiation was administered to 71% of patients, whereas 13.7% received total neoadjuvant therapy. Restorative procedures were performed in 107 patients (86.3%), whereas 17 patients (13.7%) underwent abdominoperineal resection. The majority of mesorectal excision specimens (87.09%) were complete or near complete. Local recurrence rates were 6.3% (1/16) in the incomplete and 7.4% (8/108) in the complete/near complete group ( p = 0.86). Metachronous distant metastases occurred in 6 patients (37.5%) in the incomplete group and in 24 patients (22.2%) in the complete/near complete group (p = 0.18). Thus, specimen quality did not appear to impact disease-free survival., Limitations: Retrospective, single-center study with relatively short follow-up., Conclusions: In the era of a multidisciplinary approach and extensive use of neoadjuvant therapy, macroscopic completeness of total mesorectal excision may not be as valuable a prognosticator as in the past. Larger studies with longer follow-ups are needed to clarify these preliminary findings. See Video Abstract at http://links.lww.com/DCR/C129., La Integridad De La Escisin Mesorrectal Todava Se Correlaciona Con La Recurrencia Local: ANTECEDENTES:La escisión total desl mesorrecto es el estándar de oro para el tratamiento del cáncer de recto. Varios estudios han demostrado una estrecha correlación entre el pronóstico de los pacientes con cáncer de recto y la integridad espécimen mesorrectal.OBJETIVO:Evaluar la correlación entre la evaluación macroscópica de la escisión mesorrectal y los resultados oncológicos a largo plazo en pacientes con cáncer de recto.DISEÑO:Análisis retrospectivo de una base de datos aprobada por el IRB.ENTORNO CLINICO:El estudio se realizó en un centro de referencia terciario de una sola institución.PACIENTES:Todos los pacientes con cáncer de recto operados entre 3/2016-10/2019. Los pacientes se clasificaron en 3 grupos, según la calidad del espécimen mesorrectal: completo, casi completo e incompleto. Solo se incluyeron pacientes con seguimiento >2 años y sin signos de enfermedad a distancia preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Identificar la relación entre la escisión mesorrectal total y las tasas de recurrencia local y a distancia en pacientes con cáncer de recto.RESULTADOS:Se incluyeron 124 pacientes (35,5% mujeres) con una edad media de 58,1 años (DE 12) y un índice de masa corporal medio de 26,4 (DE 4,59). Se administró quimiorradiación neoadyuvante al 71% de los pacientes, mientras que el 13,7% recibió terapia neoadyuvante total. Se realizaron procedimientos de restauración en 107 pacientes (86,3%), mientras que 17 pacientes (13,7%) se sometieron a resección abdominoperineal. La mayoría (87,09%) de los especímenes de escisión mesorrectal fueron completas o casi completas. Las tasas de recurrencia local fueron 1/16 (6,3%) en el grupo incompleto y 8/108 (7,4%) en el grupo completo/casi completo ( p = 0,86). Se produjeron metástasis a distancia metacrónicas en 6 pacientes (37,5%) en el grupo incompleto y 24 (22,2%) en el grupo completo/casi completo ( p = 0,18). Por lo tanto, la calidad del espécimen no pareció afectar la supervivencia libre de enfermedad.LIMITACIONES:Estudio retrospectivo de un solo centro con pequeño número de casos y seguimiento relativamente corto.CONCLUSIÓN:En la era de un enfoque multidisciplinario y el uso extensivo de la terapia neoadyuvante, la integridad macroscópica de la escisión total del mesorrecto, puede no ser un pronóstico tan valioso como en el pasado. Se necesitan estudios más amplios con períodos de seguimiento más prolongados para aclarar estos hallazgos preliminares. Consulte Video Resumen en http://links.lww.com/DCR/C129 . (Traducción-Dr. Fidel Ruiz Healy )., (Copyright © The ASCRS 2023.)

Importance: Rectal cancer management has significantly evolved over the last 2 decades., Objective: This study aimed to evaluate trends in the characteristics, treatment, and outcomes of rectal adenocarcinoma across 16 years., Design, Setting, and Participants: This retrospective, observational case series study used data from the National Cancer Database (NCDB) to evaluate patients diagnosed with rectal adenocarcinoma from 2004 through 2019. Data analysis was performed from March to May 2022., Exposures: Trends in the treatment and outcomes of rectal adenocarcinoma in the US between 2004 and 2019 were explored. This period was subdivided into 4 equal periods: 2004-2007, 2008-2011, 2012-2015, and 2016-2019., Main Outcomes and Measures: Patient and tumor characteristics, treatments, short-term outcomes, and overall survival., Results: A total of 318 548 patients diagnosed with rectal adenocarcinoma were included in the analysis, 191 369 (60.1%) of whom were males and 127 179 (39.9%%) were females. The mean (SD) age of the patients was 63.5 (13.4) years, and 46 824 patients (14.8%) were younger than 50 years. Among the patients, 10 859 (3.4%) were of Asian race and ethnicity, 28 464 (8.9%) were Black, and 271 236 (85.1%) were White. The percentage of patients younger than 50 years who were diagnosed with rectal cancer increased by 1.5%, from 13.9% in period 1 to 15.4% in period 4. Patients in the last period (2016-2019) presented more often with stages III (36.2% vs 30.2% vs 25.0% vs 23.4%; P < .001) and IV (21.5% vs 19.3% vs 18.1% vs 18.6%; P < .001) disease compared with those in the remaining 3 periods. The use of chemotherapy (36.8% vs 48.1% vs 49.1% vs 47.0%; P < .001) and immunotherapy (0.4% vs 0.2% vs 3.5% vs 6.5%; P < .001) significantly increased across the 4 periods. Although neoadjuvant radiotherapy was used more often across the periods studied (28.6% in period 1 to 34.3% in period 4), the use of adjuvant radiotherapy was reduced by half (12.9% to 6.0%). The median (IQR) time from diagnosis to definitive surgery increased from 95 (15-126) days in period 1 to 128 (47-158) days in period 4. The rate of use of open surgery decreased by half (60.1% in period 2 to 30.1% in period 4), and the use of robotic surgery significantly increased (5.2% in period 2 to 28.4% in period 4). The conversion rate was significantly reduced (11.2% in period 2 to 7.3% in period 4) and the median (IQR) hospital stay decreased by 2 days, from 6 (3-9) days to 4 (2-7) days. The median (IQR) overall survival significantly increased across the periods (from 83.1 months [95% CI, 81.8-84.6 months] in period 1 to 92.1 months [95% CI, 90.2-93.6 months] in period 3; P < .001)., Conclusion and Relevance: The findings of this case series study suggest a treatment trend of increased use of chemotherapy, immunotherapy, sphincter-saving surgery, and minimally invasive surgery. In addition, the time between diagnosis and definitive surgery increased by a median of 33 days. This treatment trend was associated with a significant improvement in the overall survival, reduction in the conversion rate by 3.9%, and a 2-day shorter hospital stay. These findings have major clinical relevance to the management of rectal cancer. The improvements seen in short-term outcomes and survival of patients diagnosed with rectal cancer can probably be attributed to the treatment trends observed. Continued improvement in outcomes warrant further updates in treatments.

Background: T4 rectal cancer is a challenging condition owing to the highly invasive nature of the tumour that may compromise R0 resection. The present study aimed to assess the outcomes of laparoscopic versus robotic-assisted resection of non-metastatic T4 rectal adenocarcinoma., Methods: This was a retrospective propensity score-matched analysis using the National Cancer Database between 2010 and 2019. Patients with pathological T4 non-metastatic rectal adenocarcinoma who underwent laparoscopic or robotic-assisted resection were compared and a propensity score-matched analysis was performed in a 1:1 manner. The main outcome measures were conversion to open surgery, mortality, readmission, resection margins, and overall survival., Results: After propensity score matching, 235 patients were included in each group. There were 260 (55.3 per cent) men and 210 (44.7 per cent) women, with a mean (s.d.) age of 61 (13.2) years. Patients in the robotic group had a statistically significantly lower conversion rate (8.9 per cent versus 17.9 per cent; P = 0.006), shorter median duration of hospital stay (5 versus 6 days; P = 0.007), higher overall survival rate (56.2 per cent versus 43.4 per cent; P = 0.007), and a longer median survival (60.8 versus 43.2; P = 0.025). There were no significant differences between the two groups with regard to positive resection margins, examined lymph nodes, 30-day and 90-day mortality rates, and 30-day readmission rate., Conclusions: Robotic resections of T4 rectal cancer were associated with a significantly lower conversion rate and shorter duration of hospital stay than laparoscopic resections. The two approaches were comparable with regard to positive resection margins, short-term mortality, and readmission., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Circumferential resection margin is an important prognosticator for total mesorectal excision outcome. We investigated the status of mesorectal fascia on magnetic resonance imaging compared with circumferential resection margin on pathology and factors associated with status change., Methods: This was a retrospective analysis of a prospective database of rectal cancer patients who underwent surgery. Mesorectal fascia status on magnetic resonance imaging done before neoadjuvant therapy and circumferential resection margin status on pathology were compared. The study outcomes were factors associated with a margin status conversion between magnetic resonance imaging and pathology, and predictors of involved circumferential resection margin., Results: In total, 244 patients (average follow-up of 25.4 months) were included. Eighty-one (33.2%) patients had potentially involved mesorectal fascia in magnetic resonance imaging and 12 (4.9%) had involved circumferential resection margin in pathology. A total of 2.8% of patients had a conversion of clear mesorectal fascia in magnetic resonance imaging to involved circumferential resection margin. Abdominoperineal resection was significantly associated with this status change (odds ratio: 25, 95% confidence interval: 2.4-255.8, P = .007). In total, 7.4% of patients with potentially involved mesorectal fascia had persistently involved circumferential resection margin. Lack of total neoadjuvant therapy was associated with higher, yet statistically insignificant, odds of persistently involved circumferential resection margin (odds ratio: 12, 95% confidence interval: 0.65-220.8, P = .09). The significant independent predictors of involved circumferential resection margin were body mass index (odds ratio: 1.2, P = .016) and abdominoperineal resection (odds ratio: 4.22, P = .04)., Conclusion: Change of clear mesorectal fascia in magnetic resonance imaging to an involved circumferential resection margin in pathology was recorded in 2.8% of patients; abdominoperineal resection might be associated with this change. Approximately 7% of patients had persistent involvement of circumferential resection margin as determined by pathology. Omission of total neoadjuvant therapy might be associated with persistent margin involvement., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Hartmann's procedure (HP) is used in surgical emergencies such as colonic perforation and colonic obstruction. "Temporary" colostomy performed during HP is not always reversed in part due to potential morbidity and mortality associated with reversal. There are several contributing factors for patients requiring a permanent colostomy following HP. Therefore, there is still some discussion about which technique to use. The aim of this study was to evaluate perioperative variables of patients undergoing Hartmann's reversal using a laparoscopic and open approach., Methods: The multicenter retrospective cohort study was done between January 2009 and December 2019 at 14 institutions globally. Patients who underwent Hartmann's reversal laparoscopic (LS) and open (OS) approaches were evaluated and compared. Sociodemographic, preoperative, intraoperative variables, and surgical outcomes were analyzed. The main outcomes evaluated were 30-day mortality, length of stay, complications, and postoperative outcomes., Results: Five hundred and two patients (264 in the LS and 238 in the OS group) were included. The most prevalent sex was male in 53.7%, the most common indication was complicated diverticular disease in 69.9%, and 85% were American Society of Anesthesiologist (ASA) II-III. Intraoperative complications were noted in 5.3% and 3.4% in the LS and OS groups, respectively. Small bowel injuries were the most common intraoperative injury in 8.3%, with a higher incidence in the OS group compared with the LS group (12.2% vs. 4.9%, p  < 0.5). Inadvertent injuries were more common in the small bowel (3%) in the LS group. A total of 17.2% in the OS versus 13.3% in the LS group required intensive care unit (ICU) admission ( p  = 0.2). The most frequent postoperative complication was ileus (12.6% in OS vs. 9.8% in LS group, p  = 0.4)). Reintervention was required mainly in the OS group (15.5% vs. 5.3% in LS group, p  < 0.5); mortality rate was 1%., Conclusions: Laparoscopic Hartmann's reversal is safe and feasible, associated with superior clinical outcomes compared with open surgery., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background: Endoscopic mucosal resection (EMR) is the primary treatment modality for superficial gastrointestinal mucosal lesions > 2 cm. However, the procedure carries some risk of complications including bleeding, perforation, and local recurrence. This study aimed to examine factors associated with EMR outcomes, especially in terms of local recurrence., Methods: This study retrospectively evaluated patients who underwent EMR and full closure with prophylactic clips for upper and lower gastrointestinal lesions > 2 cm at Cleveland Clinic Florida, between January 2013 and December 2018 with follow-up endoscopic evaluation for recurrence., Results: A total of 2031 endoscopic polypectomy cases were examined; 307 EMR procedures among 271 patients (52% were female, mean age 65.6 ± 11.1 years) who satisfied the inclusion criteria were included in the study. There were no perforations reported. The rate of post-polypectomy delayed bleeding was 1.6%, and the local recurrence rate in this cohort was 7.1%. Recurrent cases were successfully endoscopically managed. In the multivariate regression analysis, age > 70 years (OR = 3.20, 95% CI 1.17-8.76, p = .023), body mass index (OR = 1.12, 95% CI 1.03-1.23 p = .008), and lesion size ≥ 35 mm (OR = 11.51, 95% CI 3.54-37.40, p =  < .001) were independent predictors for recurrence., Conclusions: Age > 70 years, increased lesion size, and obesity were found to be independent predictors of local recurrence among EMR procedures for gastrointestinal lesions > 2 cm. However, there is a need for larger-scale studies on this topic., (© 2022. Springer Nature Switzerland AG.)

Objectives: The aim of this study was to evaluate the mineral content, expressed by calcium (Ca) and phosphate (P), in dental enamel exposed to bleaching agents using micro-computed tomography (micro-CT), scanning electron microscopy (SEM), energy dispersive spectroscopy (EDS), and atomic force microscopy (AFM)., Methods: Sixty bovine dental enamel specimens were randomly divided into three groups (n=20): HP35ca (bleached using 35% hydrogen peroxide with Ca); HP35wca (bleached using 35% hydrogen peroxide without Ca); and control (without bleaching). Five specimens from each group were used for SEM and EDS analyses, 10 specimens were used for AFM analysis, and the remaining five specimens were used for micro-CT analysis. The pH of the gels was measured using a pH meter. The EDS and micro-CT data were analyzed using one-way ANOVA and Pearson's correlation test. The AFM data were analyzed using one-way ANOVA (α=0.05)., Results: The weight percentages of Ca and P obtained using EDS were similar between the bleached and control groups. Small, superficial changes were observed by SEM in the HP35wca group. The HP35ca group showed similar patterns to the control group. AFM results showed no significant changes in the enamel roughness in any of the tested groups. No significant difference in the volume or depth of structural enamel loss was found between gels with and without Ca. No mineral loss was observed in the dentin substrate. The EDS and micro-CT analysis data exhibited a high correlation (p<0.001)., Conclusion: The addition of Ca to the bleaching gel had no beneficial effect on the bleached tooth enamel in terms of composition, mineral loss, and surface roughness. Micro-CT results exhibited a high correlation with the EDS results., (©Operative Dentistry, 2022.)

Aim: The aim of this work was to evaluate whether normalized carcinoembryonic antigen (CEA) following neoadjuvant chemoradiation predicts the prognosis following curative resection in locally advanced rectal cancer., Method: Patients who underwent neoadjuvant chemoradiation and curative resection for locally advanced rectal cancer between 2010 and 2015 were divided into three groups: Group A (n = 119, normal-to-normal): normal CEA before and after neoadjuvant chemoradiation; Group B (n = 37, high-to-normal): elevated CEA before and normal CEA after neoadjuvant chemoradiation; Group C (n = 36, high-to-high): elevated CEA before and after neoadjuvant chemoradiation. Overall and disease-free survival were compared. Univariate and multivariate analyses identified potential predictors for recurrence., Results: One hundred and ninety two patients [median age 59 years (range 31-87), 65.1% male] were identified: 54.7% had low rectal cancer: 12.5% were clinical stage T4 and 70.3% were clinically node positive; 21.9% achieved complete pathological response; 24.5% had abdominoperineal resection (APR); and 70.3% underwent adjuvant chemotherapy following curative resection. Significantly more patients in Group C underwent APR (p = 0.0209), had advanced pathological T stage (P = 0.0065) and a higher prevalence of perineural invasion (p = 0.0042). Overall and disease-free survival were significantly higher for Group A than for Group C [hazard ratio (HR) = 4.32, 95% CI = 1.66-11.21, p = 0.0026 and HR=2.68, 95% CI = 1.33-5.40, p = 0.0057, respectively]. No significant difference was noted between Groups A and B for overall (p = 0.0591) or disease-free (p = 0.2834) survival. Another risk factor associated with recurrence and death was clinical T4 stage; nodal positivity was a risk factor only for recurrence., Conclusion: Elevated CEA after neoadjuvant chemoradiation and clinical stage T4 disease were unfavourable predictors for overall and disease-free survival. Normalized CEA during neoadjuvant chemoradiation may serve as a prognosticator, although pretreatment CEA may significantly affect survival., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Adipose tissue is now recognized as an active organ with an important homeostatic function in glucose and lipid metabolism and the development of insulin resistance. The present research investigates the role of lipid mediators and lipid profiling for controlling inflammation and the metabolic normal function of white adipose tissue from rats suffering from diet-induced prediabetes. Additionally, the contribution to the adipose lipidome induced by the consumption of marine ω-3 PUFAs as potential regulators of inflammation is addressed. For that, the effects on the inflammatory response triggered by high-fat high-sucrose (HFHS) diets were studied in male Sprague-Dawley rats. Using SPE-LC-MS/MS-based metabolo-lipidomics, a range of eicosanoids, docosanoids and specialized pro-resolving mediators (SPMs) were measured in white adipose tissue. The inflammatory response occurring in prediabetic adipose tissue was associated with the decomposition of ARA epoxides to ARA-dihydroxides, the reduction of oxo-derivatives and the formation of prostaglandins (PGs). In an attempt to control the inflammatory response initiated, LOX and non-enzymatic oxidation shifted toward the production of the less pro-inflammatory EPA and DHA metabolites rather than the high pro-inflammatory ARA hydroxides. Additionally, the change in LOX activity induced the production of intermediate hydroxides precursors of SPMs as protectins (PDs), resolvins (Rvs) and maresins (MaRs). This compensatory mechanism to achieve the restoration of tissue homeostasis was significantly strengthened through supplementation with fish oils. Increasing proportions of ω-3 PUFAs in adipose tissue significantly stimulated the formation of DHA-epoxides by cytochrome P450, the production of non-enzymatic EPA-metabolites and prompted the activity of 12LOX. Finally, protectin PDX was significantly reduced in the adipose tissue of prediabetic rats and highly enhanced through ω-3 PUFAs supplementation. Taken together, these actively coordinated modifications constitute key mechanisms to restore adipose tissue homeostasis with an important role of lipid mediators. This compensatory mechanism is reinforced through the supplementation of the diet with fish oils with high and balanced contents of EPA and DHA. The study highlights new insides on the targets for effective treatment of incipient diet-induced diabetes and the mechanism underlying the potential anti-inflammatory action of marine lipids., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer AG-I declared a shared affiliation with several of the authors (IM, GD, LM, JT and SR) to the handling editor at the time of the review., (Copyright © 2021 Dasilva, Lois, Méndez, Miralles-Pérez, Romeu, Ramos-Romero, Torres and Medina.)

Background: The proposed difficulty scoring system (DSS) may aid in preoperative planning for laparoscopic total mesorectal excision (L-TME) for rectal cancer., Methods: Fifty-three patients [28 males; 59.0 (31.0-88.0) years of age] treated for rectal cancer at our institution from 2/2011-5/2018 were identified. "Difficult operation" (DO) was defined as the presence of ≥3 factors: operative time ≥320 min, estimated blood loss >250 ml, intraoperative complications, conversion to laparotomy, >2 stapler applications, incomplete TME quality, and/or subjective perceived difficulty. Univariate analysis and multivariate logistic regression model with backward elimination method were used to obtain a DSS which consists of two factors: sex (male = 1 and female = 0) and body mass index (BMI) (≥30 kg/m 2  = 1, <30 kg/m 2  = 0)., Results: In univariate analysis, sex (p = 0.0217), BMI (p = 0.0026), American Society of Anesthesiologists (ASA) score (p = 0.0372), and magnetic resonance imaging transverse diameter (p = 0.0441) correlated to DO. Multivariate analysis revealed that sex and BMI were the most important risk factors for a DO [area under the receiver operating characteristic curve [AUC] = 0.7761, 95% CI = (0.6443-0.9080)]. Male patients with a BMI ≥ 30 kg/m 2 were more likely to experience a DO (77.8%). The simplified DSS did not weaken the discriminating power compared to multivariate logistic regression model (AUC 0.7696 vs. 0.7761, p = 0.7387). L-TME with a DSS of 0, 1, and 2 had a DO rate of 10%, 33.3%, and 77.8%, respectively., Conclusions: A simplified DSS may be used preoperatively in preparation for L-TME.

Background: Restorative total proctocolectomy with IPAA may not be feasible in some patients because of technical intraoperative limitations., Objective: This study aimed to assess preoperative predictors for intraoperative IPAA and review management., Design: This is a retrospective review., Setting: This study was conducted at Cleveland Clinic between January 2010 and May 2018., Patients: Patients ≥18 years of age who underwent ileoanal pouch surgery were included. Patients with successful pouch creation as planned were grouped as "successful IPAA creation." Operative reports of patients who underwent alternative procedures were reviewed to identify cases when the pouch was preoperatively planned but intraoperatively abandoned (IPAA-abandoned group). Multivariate logistic regression models were developed to determine predictors of intraoperative pouch abandonment. We also reviewed the management of patients in whom the initial pouch creation failed., Main Outcome Measures: The primary outcomes measured were preoperative predictors for intraoperative ileoanal pouch abandonment., Results: A total of 1438 patients were offered an ileoanal pouch; 21 (1.5%) experienced pouch abandonment due to inadequate reach (n = 17) and other technical reasons (n = 4). These patients underwent alternative procedures such as end or loop ileostomy with/without proctectomy. Multivariate logistic regression analysis indicated male sex (OR, 6.021; 95% CI, 1.540-23.534), BMI (OR, 1.217; 95% CI, 1.114-1.329), and a 2-stage procedure (OR, 14.510; 95% CI, 4.123-51.064) as independent factors associated with intraoperative abandonment of pouch creation. Alternative procedures were total proctocolectomy with end ileostomy (n = 14) and total abdominal colectomy with end ileostomy without proctectomy (n = 7). Ultimately, pouch creation was achieved in 6 of 21 patients after a median interval of 8.8 (range, 4.1-34.8) months. All patients had intentional weight loss before a reattempt and total abdominal colectomy with end ileostomy without proctectomy as their initial procedure., Limitations: This study was limited by its retrospective nature., Conclusions: Ileoanal pouch abandonment is rare and can be mitigated by initial total abdominal colectomy and weight loss. Male, obese patients are at a higher risk of failure. Intraoperative assessment of ileoanal pouch feasibility should occur before rectal dissection. See Video Abstract at http://links.lww.com/DCR/B156. PREDICCIÓN MULTIVARIANTE DEL ABANDONO INTRAOPERATORIO DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL: La proctocolectomía total restaurativa con anastomosis de bolsa ileoanal puede no ser posible en algunos pacientes debido a limitaciones técnicas intraoperatorias.Evaluar los predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal y revisar el manejo.Revisión retrospectiva.Cleveland Clinic entre Enero de 2010 y mayo de 2018.Pacientes > 18 años que se sometieron a cirugía de bolsa ileoanal. Los pacientes con una creación exitosa de la bolsa según lo planeado se agruparon como "creación exitosa de anastomosis de bolsa ileoanal". Se revisaron los informes operativos de los pacientes que se sometieron a procedimientos alternativos para identificar los casos en que la bolsa se planificó preoperatoriamente pero se abandonó intraoperatoriamente (grupo de "anastomosis anal de bolsa ileoanal abandonada"). Se desarrollaron modelos de regresión logística multivariante para determinar los predictores del abandono intraoperatorio de la bolsa. También revisamos el manejo de pacientes que fallaron en la creación inicial de la bolsa.Predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal.A un total de 1438 pacientes se les ofreció una bolsa ileoanal; 21 (1.5%) experimentaron abandono de la bolsa debido a un alcance inadecuado (n = 17) y otras razones técnicas (n = 4). Estos pacientes se sometieron a procedimientos alternativos como ileostomía final o de asa con / sin proctectomía. El análisis de regresión logística multivariante indicó género masculino (OR, 6.021; IC 95%, 1.540-23.534), índice de masa corporal (OR, 1.217; IC 95%, 1.114-1.329) y procedimiento en 2 etapas (OR, 14.510; IC 95%, 4.123-51.064) como factores independientes asociados con el abandono intraoperatorio de la creación de la bolsa. Los procedimientos alternativos fueron la proctocolectomía total con ileostomía final (n = 14) y la colectomía abdominal total con ileostomía final sin proctectomía (n = 7). Finalmente, la creación de la bolsa se logró en 6/21 pacientes después de un intervalo medio de 8.8 (rango, 4.1-34.8) meses. Todos los pacientes tuvieron pérdida de peso intencional antes de la reintenta y colectomía abdominal total con ileostomía final sin proctectomía como procedimiento inicial.Naturaleza retrospectiva.El abandono de la bolsa ileoanal es raro y puede mitigarse mediante la colectomía abdominal total inicial y la pérdida de peso. Los pacientes masculinos y obesos tienen un mayor riesgo de fracaso. La evaluación intraoperatoria de la viabilidad de la bolsa ileoanal debe ocurrir antes de la disección rectal. Consulte Video Resumen en http://links.lww.com/DCR/B156. (Traducción-Dr. Yesenia Rojas-Kahlil).

The evolutionary history of hominins has been characterized by significant dietary changes, which include the introduction of meat eating, cooking, and the changes associated with plant and animal domestication. The Western pattern diet has been linked with the onset of chronic inflammation, and serious health problems including obesity, metabolic syndrome, and cardiovascular diseases. Diets enriched with ω-3 marine PUFAs have revealed additional improvements in health status associated to a reduction of proinflammatory ω-3 and ω-6 lipid mediators. Lipid mediators are produced from enzymatic and non-enzymatic oxidation of PUFAs. Interest in better understanding the occurrence of these metabolites has increased exponentially as a result of the growing evidence of their role on inflammatory processes, control of the immune system, cell signaling, onset of metabolic diseases, or even cancer. The scope of this review has been to highlight the recent findings on: a) the formation of lipid mediators and their role in different inflammatory and metabolic conditions, b) the direct use of lipid mediators as antiinflammatory drugs or the potential of new drugs as a new therapeutic option for the synthesis of antiinflammatory or resolving lipid mediators and c) the impact of nutritional interventions to modulate lipid mediators synthesis towards antiinflammatory conditions. In a second part, we have summarized methodological approaches (Lipidomics) for the accurate analysis of lipid mediators. Although several techniques have been used, most authors preferred the combination of SPE with LC-MS. Advantages and disadvantages of each method are herein addressed, as well as the main LC-MS difficulties and challenges for the establishment of new biomarkers and standardization of experimental designs, and finally to deepen the study of mechanisms involved on the inflammatory response., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The observation of inferior oncologic outcomes after surgery for proximal colon cancers has led to the investigation of alternative treatment strategies, including surgical procedures and neoadjuvant systemic chemotherapy in selected patients., Objective: The purpose of this study was to determine the accuracy of CT staging in proximal colon cancer in detecting unfavorable pathologic features that may aid in the selection of ideal candidates alternative treatment strategies, including extended lymph node dissection and/or neoadjuvant chemotherapy., Design: This was a retrospective consecutive series., Settings: Trained abdominal radiologists from 2 centers performed a blinded review of CT scans obtained to locally stage proximal colon cancer according to previously defined prognostic groups, including T1/2, T3/4, N+, and extramural venous invasion. CT findings were compared with histopathologic results as a reference standard. Unfavorable pathologic findings included pT3/4, pN+, or extramural venous invasion., Patients: Consecutive patients undergoing right colectomy in 2 institutions between 2011 and 2016 were retrospectively reviewed from a prospectively collected database., Main Outcome Measures: T status, nodal status, and extramural venous invasion status comparing CT with final histologic findings were measured., Results: Of 150 CT scans reviewed, CT failed to identify primary cancer in 18%. Overall accuracy of CT to identify unfavorable pathologic features was 63% with sensitivity, specificity, positive predictive value, and negative predictive value of 63% (95% CI, 54%-71%), 63% (95% CI, 46%-81%), 87% (95% CI, 80%-94%) and 30% (95% CI, 18%-41%). Only cT3/4 (55% vs 45%; p = 0.001) and cN+ (42% vs 58%; p = 0.02) were significantly associated with correct identification of unfavorable features at final pathology. CT scans overstaged and understaged cT in 23.7% and 48.3% and cN in 28.7% and 53.0% of cases., Limitations: The study was limited by its retrospective design, relatively small sample size, and heterogeneity of CT images performed in different institutions with variable equipment and technical details., Conclusions: Accuracy of CT scan for identification of pT3/4, pN+, or extramural venous invasion was insufficient to allow for proper identification of patients at high risk for local recurrence and/or in whom to consider alternative treatment strategies. Locoregional overstaging and understaging resulted in inappropriate treatment strategies in <48%. See Video Abstract at http://links.lww.com/DCR/A935.

A non-targeted strategy to simultaneously screen for over 100 lipid mediators from ω-6 ARA and ω-3 EPA and DHA fatty acids is presented. The method based on an extensive study of fragmentation patterns obtained by SPE-LC-MS/MS analysis-provided fingerprints to comprehensively elucidate and identify lipid mediators in biological samples. Many of these metabolites are associated to metabolic disorders, inflammatory, immune and oxidative stress. The methodology consisted of a three-step procedure. (1) SPE extraction of compounds from plasma and adipose tissue was followed by LC-MS/MS analysis operating in full scan mode. The methodology was validated for a group of 65 metabolites using standards. SPE recoveries ranged from 29-134% and matrix effect from 10-580%. LOD and LOQ ranged from 0.01 to 1765 ng/mL and 0.03 to 5884 ng/mL respectively, similarly than current analytical strategies based on MRM mode. (2) An extensive study of the mass spectra of a wide range of compounds was done to stablish a specific fragmentation pattern. Interestingly, illustrative fragmentations and new specific transitions to identify EPA and DHA lipid mediators have been innovatively established. (3) After analysis, 30 lipid mediators were tentatively identified in plasma and 35 in adipose tissue of rats according to the pre stablished fragmentation patterns. The hypothetical identification of compounds was validated by using reference standards. Around 85-90% of proposed identifications were correctly assigned and only 4 and 3 identifications failed in adipose tissue and plasma, respectively. The method allowed the identification of these metabolites without losing information by the use of predefined ions list. Therefore, the use of full scan mode together with the study of fragmentation patterns provided a novel and stronger analytical tool to study the complete profile of lipid mediators in biological samples than the analysis through MRM based methods. Importantly, no analytical standards were required at this qualitative screening stage and the performance and sensitivity of the assay were very similar to that of a MRM method.

Introduction: Preoperative colonoscopic localization for resection of colonic neoplasia, with or without tattooing for guidance, has been extensively used with variable accuracy. Difficulty in intraoperative identification of the lesion may lead to resection of an incorrect segment or to a more extensive resection than originally planned. The aim of this study was to evaluate the accuracy of preoperative colonoscopy in determining the site of the lesion., Methods: A prospectively collected IRB-approved institutional database was retrospectively queried for all consecutive patients who underwent an elective colon resection for neoplasia between 2013 and 2016. Excluded were patients without preoperative colonoscopy reports available for comparison or who underwent emergency surgery. Surgical plan based on preoperative colonoscopic localization with or without tattooing was compared to the final surgery and pathology reports., Results: 203 patients were included [mean age 68 (35-92) years; 102 males (50.2%)]. Preoperative colonoscopy was inaccurate in 16.7% (34 patients) leading to a change in the surgical plan. Patients with transverse or distal lesions were more likely to have a change in final surgical management compared to proximal sided lesions (29.7% vs. 3.9%, respectively; p < 0.001). Only 3.8% of the tattooed lesions could not be identified during surgery. Additional intraoperative colonoscopy was needed in 11 patients (5.5%) to verify exact lesion location. Average length of the resected segment was longer in patients who required a change in surgical plan (26.44 cm vs. 22.47 cm; p = 0.02)., Conclusion: Inaccurate preoperative colonoscopic localization led to a change in surgical management in 16.7% of cases, especially in transverse or left sided lesions. Surgeons should consider these findings when planning colonic resections.

The present study addressed the ability of long-chain ω-3 polyunsaturated fatty acids (ω-3 PUFA), i.e., eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), to ameliorate liver protein damage derived from oxidative stress and induced by consumption of high-caloric diets, typical of Westernized countries. The experimental design included an animal model of Sprague-Dawley rats fed high-fat high-sucrose (HFHS) diet supplemented with ω-3 EPA and DHA for a complete hepatic proteome analysis to map carbonylated proteins involved in specific metabolic pathways. Results showed that the intake of marine ω-3 PUFA through diet significantly decreased liver protein carbonylation caused by long-term HFHS consumption and increased antioxidant system. Fish oil modulated the carbonylation level of more than twenty liver proteins involved in critical metabolic pathways, including lipid metabolism (e.g., albumin), carbohydrate metabolism (e.g., pyruvate carboxylase), detoxification process (e.g., aldehyde dehydrogenase 2), urea cycle (e.g., carbamoyl-phosphate synthase), cytoskeleton dynamics (e.g., actin), or response to oxidative stress (e.g., catalase) among others, which might be under the control of diet marine ω-3 PUFA. In parallel, fish oil significantly changed the liver fatty acid profile given by the HFHS diet, resulting in a more anti-inflammatory phenotype. In conclusion, the present study highlights the significance of marine ω-3 PUFA intake for the health of rats fed a Westernized diet by describing several key metabolic pathways which are protected in liver.

Scope: The goals of this work are to test if d-fagomine, an iminosugar that reduces body weight gain, can delay the appearance of a fat-induced prediabetic state in a rat model and to explore possible mechanisms behind its functional action., Methods and Results: Wistar Kyoto rats were fed a high-fat diet supplemented with d-fagomine (or not, for comparison) or a standard diet (controls) for 24 weeks. The variables measured were fasting blood glucose and insulin levels; glucose tolerance; diacylglycerols as intracellular mediators of insulin resistance in adipose tissue (AT), liver, and muscle; inflammation markers (plasma IL-6 and leptin, and liver and AT histology markers); eicosanoids from arachidonic acid as lipid mediators of inflammation; and the populations of Bacteroidetes, Firmicutes, Enterobacteriales, and Bifidobacteriales in feces. It was found that d-fagomine reduces fat-induced impaired glucose tolerance, inflammation markers, and mediators (hepatic microgranulomas and lobular inflammation, plasma IL-6, prostaglandin E 2 , and leukotriene B 4 ) while attenuating the changes in the populations of Enterobacteriales and Bifidobacteriales., Conclusion: d-Fagomine delays the development of a fat-induced prediabetic state in rats by reducing low-grade inflammation. We suggest that the anti-inflammatory effect of d-fagomine may be linked to a reduction in fat-induced overpopulation of minor gut bacteria., (© 2018 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Insulin resistance (IR) and impaired glucose tolerance (IGT) are the first manifestations of diet-induced metabolic alterations leading to Type 2 diabetes, while hypertension is the deadliest risk factor of cardiovascular disease. The roles of dietary fat and fructose in the development of IR, IGT, and hypertension are controversial. We tested the long-term effects of an excess of fat or sucrose (fructose/glucose) on healthy male Wistar-Kyoto (WKY) rats. Fat affects IR and IGT earlier than fructose through low-grade systemic inflammation evidenced by liver inflammatory infiltration, increased levels of plasma IL-6, PGE 2 , and reduced levels of protective short-chain fatty acids without triggering hypertension. Increased populations of gut Enterobacteriales and Escherichia coli may contribute to systemic inflammation through the generation of lipopolysaccharides. Unlike fat, fructose induces increased levels of diacylglycerols (lipid mediators of IR) in the liver, urine F 2 -isoprostanes (markers of systemic oxidative stress), and uric acid, and triggers hypertension. Elevated populations of Enterobacteriales and E. coli were only detected in rats given an excess of fructose at the end of the study. Dietary fat and fructose trigger IR and IGT in clearly differentiated ways in WKY rats: early low-grade inflammation and late direct lipid toxicity, respectively; gut microbiota plays a role mainly in fat-induced IR, and hypertension is independent of inflammation-mediated IR. The results provide evidence that suggests that the combination of fat and sugar is potentially more harmful than fat or sugar alone when taken in excess.

Previous research showed that increasing the proportion of docosahexaenoic acid (DHA) in marine lipid supplements significantly reduces associated health benefits compared with balanced eicosapentaenoic acid (EPA):DHA supplementation Dasilva et al., 2015 [1]. It was therefore hypothesized that the EPA and DHA molecules might have differential resistance to oxidation during gastric digestion and that the oxidation level achieved could be inversely correlated with intestinal absorption and, hence, with the resultant health benefits. Accordingly, we tested this proposed mechanism of action by investigating the degree of oxidation in the stomach, and the levels of bioaccessible lipids, of varying molar proportions of DHA and EPA (2:1, 1:1 and 1:2) using the dynamic gastrointestinal tract model TIM-1. In addition, small intestine enterocyte absorption and metabolism were simulated by Caco-2 cell monolayers that were incubated with these same varying proportions of DHA and EPA, and comparing oxidized and nonoxidized polyunsaturated fatty acids (PUFAs). The results show an inverse correlation between lipid oxidation products in the stomach and the levels of bioaccessible lipids. The balanced 1:1 EPA:DHA diet resulted in lower oxidation of PUFAs during stomach digestion relative to the other ratios tested. Finally, cell-based studies showed significantly lower assimilation of oxidized EPA and DHA substrates compared to nonoxidized PUFAs, as well as significant differences between the net uptake of EPA and DHA. Overall, the present work suggests that the correct design of diets and/or supplements containing marine lipids can strongly influence the stability and bioaccessibility of PUFAs during gastrointestinal digestion and subsequent absorption. This could modulate their health benefits related with inflammation, oxidative stress and metabolic disorders., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The meta-xylylene diradical m-C 8 H 8 is a prototypical organic triplet that represents a building block for organic molecule-based magnets and also serves as a model compound for test and refinement of quantum chemical calculations. Flash vacuum pyrolysis of 1,3-bis-iodomethyl-benzene (m-C 8 H 8 I 2 ) produces m-C 8 H 8 in gas phase; we used photoelectron spectroscopy to probe the first two electronic states of the radical cation, and resolve the vibrational fine structure of the ground state band. The determined adiabatic ionization energy of m-C 8 H 8 is (7.27 ± 0.01) eV. Heat of formation of the diradical was established measuring C-I bond dissociation thresholds in the precursor cation and utilizing a thermochemical cycle to yield ΔH f,298K = (325 ± 8) kJ mol -1 , ca. 10 kJ mol -1 below the previous value.

Marine lipids, especially ω-3 polyunsaturated fatty acids (PUFAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have largely been linked to prevention of diet-induced diseases. The anti-inflammatory and hypolipidemic properties of EPA and DHA supplementation have been well-described. However, there is still a significant lack of information about their particular mechanism of action. Furthermore, repeated meta-analyses have not shown conclusive results in support of their beneficial health effects. Modern "omics" approaches, namely proteomics and lipidomics, have made it possible to identify some of the mechanisms behind the benefits of marine lipids in the metabolic syndrome and related diseases, i.e., cardiovascular diseases and type 2 diabetes. Although until now their use has been scarce, these "omics" have brought new insights in this area of nutrition research. The purpose of the present review is to comprehensively show the research articles currently available in the literature which have specifically applied proteomics, lipidomics or both approaches to investigate the role of marine lipids intake in the prevention or palliation of these chronic pathologies related to diet. The methodology adopted, the class of marine lipids examined, the diet-related disease studied, and the main findings obtained in each investigation will be reviewed., Competing Interests: The authors declare no conflict of interest.

The ability of polyphenols to ameliorate potential oxidative damage of ω-3 PUFAs when they are consumed together and then, to enhance their potentially individual effects on metabolic health is discussed through the modulation of fatty acids profiling and the production of lipid mediators. For that, the effects of the combined consumption of fish oils and grape seed procyanidins on the inflammatory response and redox unbalance triggered by high-fat high-sucrose (HFHS) diets were studied in an animal model of Wistar rats. A standard diet was used as control. Results suggested that fish oils produced a replacement of ω-6 by ω-3 PUFAs in membranes and tissues, and consequently they improved inflammatory and oxidative stress parameters: favored the activity of 12/15-lipoxygenases on ω-3 PUFAs, enhanced glutathione peroxidases activity, modulated proinflammatory lipid mediators synthesis through the cyclooxygenase (COX) pathways and down-regulated the synthesis de novo of ARA leaded by Δ5 desaturase. Although polyphenols exerted an antioxidative and antiinflammatory effect in the standard diet, they were less effective to reduce inflammation in the HFHS dietary model. Contrary to the effect observed in the standard diet, polyphenols up-regulated COX pathways toward ω-6 proinflammatory eicosanoids as PGE 2 and 11-HETE and decreased the detoxification of ω-3 hydroperoxides in the HFHS diet. As a result, additive effects between fish oils and polyphenols were found in the standard diet in terms of reducing inflammation and oxidative stress. However, in the HFHS diets, fish oils seem to be the one responsible for the positive effects found in the combined group., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Neutropenic colitis is a severe condition usually affecting immunocompromised patients. Its exact pathogenesis is not completely understood. The main elements in disease onset appear to be intestinal mucosal injury together with neutropenia and the weakened immune system of the afflicted patients. These initial conditions lead to intestinal edema, engorged vessels, and a disrupted mucosal surface, which becomes more vulnerable to bacterial intramural invasion. Chemotherapeutic agents can cause direct mucosal injury (mucositis) or can predispose to distension and necrosis, thereby altering intestinal motility. This article aims to review current concepts regarding neutropenic colitis' pathogenesis, diagnosis, and management.

Background: The over-the-scope clip (OTSC) is a novel endoscopic tool that enables non-surgical management of gastrointestinal (GI) defects. The aim of this study was to report our experience with OTSC for patients with GI defects., Methods: A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC from 2012 to 2015. Primary outcome was the clinical success of the OTSC for the individual indication. Secondary outcome was the number of additional procedures needed following OTSC., Results: Fifty-one patients were treated with OTSC: upper GI (UGI) 30 and lower GI (LGI) 21. GI leak (n = 24; UGI = 12, LGI = 12) and fistulae (n = 17; UGI = 8, LGI = 9) were the most common indications. Overall success rate for the treatment of leaks was 59 % [UGI 66 % vs. LGI 33 % (p = 0.1)]. A lower success rate (35 %) was noted for fistulae [UGI 62 % vs. LGI 0 % (p = 0.001)]. Success rates for UGI perforation, bleeding, and stent anchoring indications were 75, 75, and 50 %, respectively. Additional endoscopic or surgical interventions following OTSC were indicated in 68.6 % of the patients., Conclusions: OTSC appears to have additional value in treating UGI defects. However, lower success rates for LGI defects were noted, specifically for fistulae. Most patients require an additional endoscopic or surgical procedure after one OTSC application.

The role of specific proportions of ω-3 EPA and DHA, in the modulation of inflammation and oxidative stress markers associated to the progression of Metabolic Syndrome was investigated. Potential inflammatory eicosanoids and docosanoids were discussed together to biomarkers of CVD, obesity, inflammation and oxidative stress in an animal model of metabolic disorders. Results evidenced a noteworthy health effect of 1:1 and 2:1 EPA:DHA proportions over 1:2 EPA:DHA based diets through a down-regulation in the production of strong pro-inflammatory ω-6 eicosanoids, a decrement of biomarkers of oxidative stress, and a modulation of fatty acid desaturase activities and plasma and membrane PUFAs towards greater anti-inflammatory profiles. Outcomes contribute to the general knowledge on the health benefits of marine lipids and their role on the progress of MetS, inflammation and oxidative stress. Results shed light on controversial protective mechanisms of EPA and DHA to better design dietary interventions aimed at reducing MetS., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

It has been suggested that food components such as ω-3 polyunsaturated fatty acids (ω-3 PUFAs) and (poly)phenols counteract diet-induced metabolic alterations by common or complementary mechanisms. To examine the effects of a combination of ω-3 PUFAs and (poly)phenols on such alterations, adult Wistar-Kyoto rats were fed an obesogenic high-fat high-sucrose diet supplemented, or not, for 24 weeks with: eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA) 1 : 1 (16.6 g kg(-1) feed); proanthocyanidin-rich grape seed extract (GSE, 0.8 g kg(-1) feed); or EPA/DHA 1 : 1 + GSE. Body weight, feed intake, and plasma glucose were evaluated every 6 weeks, while adipose tissue weight, insulin, glucagon, ghrelin, leptin, adiponectin, cholesterol, and triglycerides were evaluated at the end of the experiment. ω-3 PUFAs reduced plasma leptin and cholesterol levels, but did not modify diet-induced perigonadal fat or plasma insulin levels; while GSE increased plasma triglyceride levels. The combined action of ω-3 PUFAs and the proanthocyanidins reduced plasma insulin and leptin, as well as partially prevented perigonadal fat accumulation. While separate supplementation with ω-3 PUFAs or grape proanthocyanidins may not counteract all the key metabolic changes induced by a high-energy-dense diet, the combination of both supplements reverts altered insulin, leptin and triglyceride levels to normal.

Objective: This study aimed to investigate the long-term outcomes of patients who undergo redo sphincteroplasty (RS)., Methods: Patients with fecal incontinence (FI) who underwent RS between November 1988 and December 2011 were retrospectively identified from a prospective database. A questionnaire and telephone survey assessed current Cleveland Clinic Fecal Incontinence Score (CCFFIS; best 0, worst 20) and Fecal Incontinence Quality of Life (FIQoL; best 4.1, worst 1) scale. Success was defined as no further continence surgery, no stoma and CCFFIS <9 at completion of follow-up. The Wilcoxon and Mann-Whitney U tests were used for comparing quantitative variables. Bivariate logistic regression analysis was done to identify predictive factors for success., Results: Fifty-six (66.7%) of 84 patients who underwent RS were available for evaluation at a median follow-up of 74 (range: 12-283) months. The mean CCFFIS decreased from 16.5 ± 3.7 to 11.9 ± 6.6 (P < 0.001) at last follow-up. Twelve patients (21.4%) underwent further continence surgery for failed sphincteroplasty, three (5.4%) of whom had a permanent stoma. Eighteen patients (32.1%) had a CCFFIS <9 at the completion of follow-up, and 16 (28.6%) had long-term success. Twenty-four patients evaluated for FIQoL had a mean value of 2.6 (range: 1.0-4.1). Postoperative CCFFIS was correlated with FIQoL (Spearman's correlation coefficient = -0.854, P < 0.001). Logistic regression analysis did not reveal any significant predictive variables for success of RS., Conclusion: Based on our criteria for success, the long-term success rate for RS over a median of 74 months is poor., (© The Author(s) 2015. Published by Oxford University Press and the Digestive Science Publishing Co. Limited.)

Background: Outcomes of artificial bowel sphincter reimplantation for severe fecal incontinence remain unknown., Objective: The purpose of this study was to evaluate the feasibility and outcomes of artificial bowel sphincter reimplantation versus implantation., Design: This was a retrospective review study., Settings: The study was conducted at a single institution., Patients: Patients with severe incontinence who underwent de novo implantation and re-implantation between January 1998 and December 2012 were included., Main Outcome Measures: Complications, length of functional device time, success rates (functioning device at follow-up), patient demographics, comorbidities, etiology of incontinence, operative data, postoperative complications, and outcomes of initial implantation versus reimplantation were analyzed., Results: A total of 57 patients (mean age, 49.3 ± 13.5 years; 44 women) underwent implantation. Sixteen (28%) succeeded and 41 (72%) failed, requiring explantation; 17 of 41 patients underwent reimplantation; 5 had 2 reimplantations. There were 79 implantations and 50 explantations (63.3%) in total. Implantation and reimplantation procedures had similar lengths of operation, hospital stay, postoperative complications, and explantation rate. Most common reasons for device explantation were infection/erosion (27/50 (54%)) and malfunction (19/50 (38%)). Reasons for reimplantation included device malfunction/migration (17/22 (77.3%)) and/or infection/erosion (5/22 (22.7%)). Seven (41.2%) of 17 patients for whom reimplantation was attributed to noninfectious reasons had a functioning device, whereas only 1 (20.0%) of 5 who had reimplantation because of infection/erosion had a working device. At a median follow-up of 29.5 months (range, 1.0-215.0 months), 24 patients (42%) retained a functioning device (implantation = 16; reimplantation = 8). Success rates were not significantly different between initial implantation and reimplantation procedures (p = 0.755). There were no differences in the length of functional device time between implanted and reimplanted devices (p = 0.439)., Limitations: The study was limited by its retrospective nature and small sample size., Conclusions: Artificial bowel sphincter implantation has a high failure rate, requiring explantation in 72% of patients in this study. Reimplantation was often possible, with a success rate of 47%. Selected reimplantation for noninfectious complications had better outcomes than did reimplantation for septic causes. Short- and long-term outcomes are comparable to initial implantation.

Background: Adverse events and complications have been reported after sacral neurostimulation for fecal incontinence, which may result in surgical revision and device explantation. Lead reimplantation may be feasible; however, available data regarding outcomes are less robust., Objective: The aim of this study was to determine the outcomes of sacral neurostimulation lead reimplantation for fecal incontinence., Design: This was a retrospective review of prospectively collected data., Settings: The study was conducted at 2 clinical sites from a single institution., Patients: Patients with fecal incontinence who underwent sacral neurostimulation implantation or reimplantation between 2011 and 2014 were included in the study., Interventions: Sacral neurostimulation reimplantation was the included intervention., Main Outcome Measures: Change in the Cleveland Clinic Florida Fecal Incontinence Score (0 best; 20 worst) in reimplantation as compared with index implantation controls was the main measure. Secondary outcomes included the frequency and type of adverse events and complications., Results: A total of 112 patients underwent either sacral neurostimulation implantation or reimplantation between 2011 and 2014. Ninety-seven patients underwent an index percutaneous nerve stimulation trial, 93 of whom also underwent a stimulator implantation. Fifteen patients underwent lead reimplantation, with 5 performed before stimulator implantation and 10 after stimulator implantation. The index implanted and reimplanted groups had similar demographics, comorbidities, and complication profiles including explantation rates. The most common reason for reimplantation was lead related (6/15), including 4 lead migrations, 1 lead fracture, and 1 lead erosion. Significant decreases in the incontinence score were achieved in each group (index implantation: p < 0.001; reimplantation: p = 0.006). When comparing the efficacy of sacral neurostimulation therapy in decreasing the fecal incontinence score from baseline in each group, patients with an index implantation were found to have a more significant improvement in their incontinence score as compared with the reimplantation group (p = 0.047)., Limitations: This was a retrospective study. A large number of patients with incomplete functional assessment data were excluded from analysis., Conclusions: The improvements in fecal incontinence are significantly better after index implantation than after reimplantation.

The consequences of slaughter on the formation of lipid metabolites and oxidative stability of fish muscle during long term frozen storage (-10 °C) were evaluated using farmed rainbow trout killed by asphyxia in air or percussion. The level of major adenine nucleotides and their related compounds was determined in order to check the stress level during slaughter. Plasma lipid metabolites were studied through the determination of eicosanoids and docosanoids such as prostaglandins, leukotrienes, thromboxanes, isoprostanes, resolvins, hydroxides, hydroperoxides, coming from eicosapentaenoic (EPA), arachidonic (ARA), and docosahexaenoic (DHA) acids. In addition, lipid oxidative stability of fillets was monitored. Results revealed that stress during slaughter can greatly influence oxidative stress and oxidative stability of rainbow trout fillets. In fact, asphyxia, which was the most stressful, induced a higher production of some lipid mediators such as hydroperoxides and EPA-derived prostaglandins, such as 12-HpHEPE/15-HpHEPE and PGD3/PGE3. As a consequence, fillets derived from asphyxiated fish were less stable in terms of oxidative stability and showed lower shelf-life., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Schistosomiasis is a trematode infection endemic in more than 70 countries that affects an estimated 250 million people. We report the case of a 60-year-old healthy female referred for endoscopic ultrasound after rectal examination revealed granular lesions. Ultrasound revealed the presence of deep mucosal nodular lesions with calcified/hyperechoic inclusions. Histologic evaluation has confirmed the final diagnosis of chronic schistosomal colitis. In patients with nonspecific intestinal lesions without a suspected diagnosis of schistosomiasis, endoscopic ultrasound can be enlightening. Schistosomiasis is still an endemic infection in some parts of Brazil and other tropical regions, causing colorectal lesions with unspecific presentation.

Dietary intervention with ω-3 marine fatty acids may potentially modulate inflammation and oxidative stress markers related with CVD, metabolic syndrome and cancer. The aim of this study was to evaluate whether different proportions of ω-3 EPA and DHA intake provoke a modulation of the production of lipid mediators and then, an influence on different indexes of inflammation and oxidative stress in a controlled dietary animal experiment using Wistar rats. For such scope, a lipidomic SPE-LC-ESI-MS/MS approach previously developed was applied to determine lipid mediators profile in plasma samples. The effect of ω-3 fatty acids associated to different ratios EPA:DHA was compared with the effect exerted by ω-3 ALA supplementation from linseed oil and ω-6 LA from soybean oil. CRP showed a tendency to greater inflammatory status in all ω-3-fed animals. Interestingly, ratios 1:1 and 2:1 EPA:DHA evidenced a noteworthy healthy effect generating a less oxidative environment and modulating LOX and COX activities toward a decrease in the production of proinflammatory ARA eicosanoids and oxidative stress biomarkers from EPA and DHA. In addition, the ability of 1:1 and 2:1 fish oil diets to reduce lipid mediator levels was in concurrence with the protective effect exerted by decreasing inflammatory markers as ω-6/ω-3 ratio in plasma and membranes. It was also highlighted the effect of a higher DHA amount in the diet reducing the healthy benefits described in terms of inflammation and oxidative stress. Results support the antiinflammatory and antioxidative role of fish oils and, particularly, the effect of adequate proportions EPA:DHA., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Perineal wound complications after ileoanal pouch excision remain a significant cause of morbidity., Objective: The purpose of this work was to describe the incidence, outcomes, and predictors of perineal wound complications after pouch excision., Design: This was a retrospective medical chart review., Settings: The study was conducted in a single clinical institution., Patients: Patients who underwent pouch excision at our institution from July 1992 through July 2012 were identified. Patient and perioperative variables were reviewed. Multivariate and univariate analyses were undertaken., Main Outcome Measures: Perineal wound (including perineal wound infection and persistent perineal sinus [nonhealing by 6 months]) and perineal hernia were measured., Results: A total of 47 patients (mean age, 46 years; 42.6% men) with familial adenomatous polyposis (10.6%), mucosal ulcerative colitis (61.7%), or Crohn's disease (27.7%) underwent pouch excision, including 36.2% for IPAA-related sepsis (presacral abscess; perineal-, sacral-, or pouch-vaginal fistula; and anastomotic defect), 44.7% for pouch dysfunction, 10.6% for refractory pouchitis, and 8.5% for neoplasia. Fourteen (29.8%) developed perineal wound complications, including 100% perineal wound infection, 28.6% persistent perineal sinus, and 7.1% perineal hernia. Perineal wound infection was associated with delayed healing (>6 weeks; 71.4% vs 24.2%; p = 0.002) and IPAA-related sepsis (28.6% vs 0%; p = 0.001). Patients with and without perineal wound complications were similar in age, diagnoses, fecal diversion, immunosuppression, comorbid conditions, nutrition, and surgical variables. Most patients underwent intersphincteric dissection (87.2%) with primary perineal closure (97.0%). Perineal wound complications were significantly associated with IPAA-related sepsis as an indication for pouch excision (57.1% vs 27.2%; p = 0.05), intraoperative pouch perforation (35.7% vs 9.1%, p =0.03), and smoking (21.4% vs 3.0%; p = 0.04). IPAA-related sepsis and a current smoking status (OR, 19.3 [95% CI, 1.8 -488.1]) are significant independent predictors on multivariate logistic regression (OR, 6.4 [95% CI, 1.4-30.2]) of perineal wound complications. All of the patients with persistent perineal sinus achieved successful healing at a median of 734 days (range, 363-2182 days), requiring a median of 1.5 procedures., Limitations: This was a single-center retrospective review with a small sample size., Conclusions: Preoperative IPAA-related sepsis and current smoking are significant risk factors for perineal wound complications after pouch excision.

Background: This study aimed to investigate the outcomes of sphincteroplasty in obese patients., Methods: Patients with fecal incontinence (FI) who underwent sphincter repair were identified and divided into obese [body mass index (BMI) ≥ 30 kg/m(2)] and nonobese (BMI < 30 kg/m(2)) groups. Cleveland Clinic Florida FI Score (CCFFIS: 0 best and 20 worst) and FI quality of life (FIQoL) score (mean global FIQoL: 4.11 best and 1 worst) were recorded. Wilcoxon and Mann-Whitney U tests compared quantitative variables; Fisher's exact test was used for categorical variables., Results: Seventy-nine patients (78 females; mean age: 57 ± 15 years) were divided into obese (n = 15) and nonobese (n = 64) groups and were similar in age, etiology, physiologic parameters, and preoperative CCFFIS. Median follow-up was 64 (13-138) months. There were 3 (25 %) and 11 (17 %) complications in the obese and nonobese groups, respectively (p = 0.68), the most common being wound infection. Mean CCFFIS decreased from 16.0 ± 3.9 to 11.5 ± 6.5 in the obese (p < 0.001) and 16.2 ± 3.4 to 8.4 ± 5.0 in the nonobese groups (p < 0.001). Postoperative CCFFIS correlated with FIQoL (Spearman's correlation coefficient = -0.738, p < 0.001). Nonobese patients had significantly higher CCFFIS improvement (48 vs. 28 % p = 0.04) and a superior mean global FIQoL score (2.19 ± 0.9 vs. 2.93 ± 0.8, p < 0.01). Four (29 %) obese and 11 (17 %) nonobese patients required further surgery after failed sphincteroplasty (p = 0.45)., Conclusions: Risk of complications and need of further continence surgery were similar between obese and nonobese patients. However, obese patients experienced less improvement after sphincteroplasty.