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Purpose: Cancer staging is the foundation for all cancer management decisions. For real-time use, stage must be embedded in the electronic health record as a discrete data element. The objectives of this quality improvement (QI) initiative were to (1) identify barriers to utilization of an existing discrete cancer staging module, (2) identify health information technology (HIT) solutions to support discrete capture of cancer staging data, and (3) increase capture across the oncology enterprise in our diverse health system., Methods: Six sigma QI methodologies were used to define barriers and solutions to improve discrete cancer staging. Design thinking principles informed solution development to test prototypes. Two multidisciplinary teams of disease-specific clinicians within GI and genitourinary conducted phased testing pilots to determine health system solutions. Solutions were expanded to all oncology specialties across our health system., Results: Baseline average discrete staging capture across our health system was 31%. Poor workflow efficiency, limited accountability, and technical design gaps were key barriers to timely, complete staging. Implementation of more than 25 design enhancements to a HIT solution and passive user alerts led to a postimplementation capture rate of 58% across 55 outpatient clinics involving more than 400 clinicians., Conclusion: We identified key barriers to discrete data capture and designed solutions through iterative use of QI methodologies and disease-specific pilots. After implementation, discrete capture of cancer staging nearly doubled across our diverse health system. This approach is scalable and transferable to other initiatives to develop and implement clinically relevant HIT solutions across a diverse health system.

Caring for patients with colorectal cancer inherited cancer syndromes is complex, and it requires a well-thought integration process between a multidisciplinary team, an accessible database, and a registry coordinator. This requires an aligned vision between the administrative business team and the clinical team. Although we can manage most of the cancers that those patients develop according to oncologic guidance, the future risk of patients and their families might add emotional and psychological burdens on them in the absence of a well-qualified and trained team where balancing quality of life and cancer risk are at the essence of decision making., Competing Interests: Conflict of Interest M.A.A. declares to receive consulting fees from Invitae on the ground of minimal residual testing in cancer, unrelated to this study., (Thieme. All rights reserved.)

BackgroundVenous thromboembolism (VTE) is common after bariatric surgery and extended prophylaxis is generally recommended. Low molecular weight heparin is the most commonly used agent but requires patients to be trained to self-inject and is expensive. Rivaroxaban is an oral daily formulation approved for VTE prophylaxis after orthopedic surgery. Efficacy and safety of rivaroxaban has been confirmed in major gastrointestinal resections by several observational studies. We report a single centre experience of using rivaroxaban as an agent for VTE prophylaxis in bariatric surgery. MethodsWe performed prospective cohort study assessing safety and efficacy of rivaroxaban as a medication for VTE prophylaxis in patients undergoing bariatric surgery in a single centre in Kyiv, Ukraine. Patients undergoing major bariatric procedure received perioperative prophylaxis of VTE with subcutaneous low molecular weight heparin and then were switched to rivaroxaban for total of 30 days starting on the 4th postoperative day. Thromboprophylaxis was performed in accordance with the VTE risks derived from the Caprini score. On the 3rd, 30th, 60th day after the operation, the patients underwent ultrasound examination of the portal vein, as well as the veins of the lower extremities. Telephone interviews were conducted 30 and 60 days after the surgery to evaluate the presence of complaints which may be characteristic for VTE as well as to assess compliance with the regimen and to assess patient satisfaction. Outcomes studies were incidence of VTE and adverse events related to rivaroxaban administration.Results110 patients were included in the study from July 2019 to May 2021. The average age of the patients was 43.6 years, the average preoperative BMI was 55 (35 to 75). One hundred and seven patients (97.3%) underwent laparoscopic intervention while three patients (2.7%) underwent laparotomy. Eighty-four patients underwent sleeve gastrectomy and twenty-six patients underwent other procedures, including bypass surgery. Average calculated risk of thromboembolic event was 5-6% based on Caprine index. All patients were treated with extended prophylaxis with rivaroxaban. The average follow-up period for patients was 6 months. There were no clinical or radiological evidence of thromboembolic complications in the study cohort. Overall complication rate was 7.2%, however, only one patient (0.9%) developed subcutaneous hematoma associated with rivaroxaban not requiring intervention. ConclusionExtended postoperative prophylaxis with rivaroxaban is safe and effective in preventing thromboembolic complications in patients undergoing bariatric surgery. It is preferred by patients and further studies should be considered to further evaluate its use in bariatric surgery.

Purpose: Several studies have examined effectiveness of primary fascial defect closure (FDC) versus bridged repair (no-FDC) during laparoscopic ventral hernia mesh repair (LVHMR). The purpose of this study was to systematically review and meta-analyse randomized controlled trials (RCTs) which compared safety and effectiveness of two techniques., Methods: Systematic literature searches (EMBASE, MEDLINE, PubMed, and CINAHL) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines using predefined terms. RCTs comparing FDC and no-FDC in LVHMR were identified and retrieved. Primary outcomes were risk of recurrence and risk of major complications analyzed as a single composite outcome. Secondary outcomes were risks of seroma formation, clinical or radiologically confirmed eventration, incidence of readmission to hospital, postoperative changes in quality of life (QoL), and postoperative pain. Random effects modeling to summarize statistics were performed. The risk of bias was assessed using Cohrane's Risk of Bias tool 2., Results: Three RCTs that enrolled total of 259 patients were included. There was clinical heterogeneity present between studies related to patients' characteristics, hernia characteristics, and operative techniques. There was no difference found in primary outcomes, risks of seroma formation, eventration, and chronic pain. There is conflicting evidence on how both techniques affect postoperative QoL or early postoperative pain., Conclusions: Both techniques were detected to have equal safety profile and do not differ in risk of recurrence, seroma formation, risks of clinical or radiological eventration. Giving uncertainty and clinical equipoise, another RCT examining FDC vs no-FDC laparoscopic mesh repair separately for primary and secondary hernias using narrow inclusion criteria for hernia size on well-defined population would be ethical and pragmatic., Prospero Registration: CRD42021274581., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

While generally perceived as mundane and low-risk procedures, anorectal surgeries by virtue of their anatomic real-estate-dense with nerves, blood supply, and structures critical to the quality of life-are fraught with the potential for complications. While these complications are generally not life-threatening, their impact to the quality of life can be severe. Furthermore, the sheer volume of anorectal procedures performed each year means that even low complication rates or less severe complications can have significant economic impact., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: This systematic review and meta-analysis studied the role of high (HL) versus low (LL) inferior mesenteric artery (IMA) ligation on genitourinary and defecatory dysfunction in patients who had undergone resection for rectal cancer (RC)., Methods: A systematic literature search of four major databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Randomized controlled trials (RCTs) comparing HL and LL of IMA in RC surgery were identified. Those studies that looked at genitourinary or defecatory dysfunction were included. Random-effects modeling to summarize statistics was performed. The risk of bias was assessed using Cochrane's Risk-of-Bias tool 2., Results: Three RCTs were included. There was clinical heterogeneity with regard to cancer stage and location as well as operative techniques and adjuvant treatments. Functional outcomes (FO) that were reported by at least two studies were International Consultation on Incontinence Questionnaire (ICIQ), International Index for Erectile Function (IIEF), Jorge-Wexner incontinence score (J-W). Difference was observed in ICIQ at 9 months after surgery favoring LL (standard mean difference: - 0.66; 95% confidence intervals (CI): - 0.92, - 0.40; P = 0.37; I 2 = 0%). Difference was also observed in IIEF at 9 months favoring LL (mean difference: 7.43; CI: 1.86, 13.00; P = 0.16; I 2 = 50%)., Conclusions: Although our study has demonstrated the superiority of LL in genitourinary function preservation, these results should be taken with consciousness due to significant heterogeneity between included studies, small sample size, and potential bias. More high-quality studies are needed., Prospero: CRD4202121099  https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021210998., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Patients with ulcerative colitis (UC) are at increased risk for infections such as Clostridium difficile and cytomegalovirus (CMV) colitis due to chronic immunosuppression. These patients often undergo multiple surgeries putting them at risk for recurrence of the infection. However, rates of recurrence in this setting and outcomes are not well understood., Aim: The aim of this study is to determine rates of recurrence of C difficile and CMV infection in patients undergoing multistage UC surgeries and effects of antibiotic prophylaxis on outcomes., Methods: All patients with UC who underwent IPAA between 2001 and 2017 (at two tertiary referral centers were identified. History of C. difficile or CMV colitis prior to any surgery and recurrence after IPAA was noted RESULTS: A total of 633 patients with UC who underwent IPAA were identified, of whom 8.1% patients had C. difficile and 2.7% had CMV infections. 9.8% of C. difficile and 5.9% of CMV patients recurred after IPAA. Rates of abdominal sepsis (14.7% vs. 12.7%), 90-day mortality (0% vs. 0.4%), pouchitis (36.8% vs. 45.0%), or return to stoma (7.4% vs. 5.4%) were similar between patients who did or did not have infections. In patients with C. difficile infection prior to first surgery, none of the patients who received prophylaxis had recurrent infection., Conclusions: Rates of C. difficile and CMV infections remain high in patients undergoing surgery for UC, with substantial minority developing recurrent infection during subsequent surgical procedures. Antibiotic prophylaxis in patients with a history of C difficile may reduce the rate of recurrent infection., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

<b>Introduction:</b> Barrett's esophagus is an acquired condition that develops as a result of transformation of normal stratified squamous epithelium in the lower part of the esophagus into columnar epithelium. Barrett's esophagus is considered to be a complication of gastroesophageal reflux disease (GERD). Various endoscopic techniques have been shown to be successful in the treatment of this condition. However, long-term success in preventing further esophageal dysplasia is not clear. Biological welding consists in the application of controlled high-frequency current on living tissues and has been used to stop gastrointestinal bleeding, similarly to the APC technique which involves ablation of small intestinal metaplasia of the esophageal mucosa.<br/> <b>Aim:</b> The goal of this study was to evaluate the effectiveness of endoscopic techniques in the treatment of Barrett's esophagus and verify the need for a subsequent surgical intervention in patients with GERD complicated by Barrett's esophagus. <br/><b> Material and methods: </b> Patients with Barrett's esophagus C1-3M2-4 (Prague classification from 2004) and high dysplasia without nodules, as well as patients with confirmed GERD without hiatal hernia, were included in this study. Endoscopic treatment was performed with the use of argonoplasmic coagulation (APC) and high-frequency welding of living tissues (HFW). After the examination the patients were re-examined. Patients with recurrence of metaplasia and high DeMeester score (˃ 100) underwent antireflux surgery - crurography and Nissen fundoplication with creation of a soft and short cuff.<br/><b>Results:</b> A total of 89 patients were included in the study, 81 of whom were reexamined after ablation of Barrett's esophagus.In 12 patients, a recurrence of intestinal metaplasia resembling the small intestine was identified. Implementation of two-stage treatment was required for 9 patients - it involved a second procedure of ablation of the esophagus, followed by antireflux surgery. Surgical treatment was refused by 3 patients, who underwent only the second ablation procedure. All patients received drug therapy, consisting of prokinetics and proton pump inhibitors. Esophageal pH monitoring was repeated 3 months after surgery, showing normalization of the DeMeester score. As a result, the patients experienced no complaints such as heartburn, chest pain or dysphagia, which significantly improved their quality of life. Esophagogastroduodenoscopy and biopsy of the mucous membrane of the lower third of the esophagus were performed in accordance with the Seattle Protocol. After examining histological specimens, no regions of metaplasia were identified. <br/><b>Conclusion:</b> Antireflux surgery is required as a part of the treatment for Barrett's esophagus, which prevents further dysplasia and development of esophageal cancer.<br/&gt.

Background: The National Comprehensive Cancer Network's Rectal Cancer Guideline Panel recommends American Joint Committee of Cancer and College of American Pathologists (AJCC/CAP) tumor regression grading (TRG) system to evaluate pathologic response to neoadjuvant chemoradiotherapy for locally advanced rectal cancer (LARC). Yet, the clinical significance of the AJCC/CAP TRG system has not been fully defined., Materials and Methods: This was a multicenter, retrospectively recruited, and prospectively maintained cohort study. Patients with LARC from one institution formed the discovery set, and cases from external independent institutions formed a validation set to verify the findings from discovery set. Overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were assessed by Kaplan-Meier analysis, log-rank test, and Cox regression model., Results: The discovery set (940 cases) found, and the validation set (2,156 cases) further confirmed, that inferior AJCC/CAP TRG categories were closely /ccorrelated with unfavorable survival (OS, DFS, LRFS, and DMFS) and higher risk of disease progression (death, accumulative relapse, local recurrence, and distant metastasis) (all p < .05). Significantly, pairwise comparison revealed that any two of four TRG categories had the distinguished survival and risk of disease progression. After propensity score matching, AJCC/CAP TRG0 category (pathological complete response) patients treated with or without adjuvant chemotherapy displayed similar survival of OS, DFS, LRFS, and DMFS (all p > .05). For AJCC/CAP TRG1-3 cases, adjuvant chemotherapy treatment significantly improved 3-year OS (90.2% vs. 84.6%, p < .001). Multivariate analysis demonstrated the AJCC/CAP TRG system was an independent prognostic surrogate., Conclusion: AJCC/CAP TRG system, an accurate prognostic surrogate, appears ideal for further strategizing adjuvant chemotherapy for LARC., Implications for Practice: The National Comprehensive Cancer Network recommends the American Joint Committee of Cancer and College of American Pathologists (AJCC/CAP) tumor regression grading (TRG) four-category system to evaluate the pathologic response to neoadjuvant treatment for patients with locally advanced rectal cancer; however, the clinical significance of the AJCC/CAP TRG system has not yet been clearly addressed. This study found, for the first time, that any two of four AJCC/CAP TRG categories had the distinguished long-term survival outcome. Importantly, adjuvant chemotherapy may improve the 3-year overall survival for AJCC/CAP TRG1-3 category patients but not for AJCC/CAP TRG0 category patients. Thus, AJCC/CAP TRG system, an accurate surrogate of long-term survival outcome, is useful in guiding adjuvant chemotherapy management for rectal cancer., (© 2021 AlphaMed Press.)

&lt;b&gt;Purpose: &lt;/b&gt;Venous thromboembolism (VTE) after colorectal surgery is a well-documented complication, resulting in a general recommendation of extended post-discharge prophylaxis. Rivaroxaban, a factor Xa inhibitor, is a daily tablet approved for treatment of VTE and prophylaxis after orthopedic surgery. &lt;br&gt;&lt;b&gt;Aim: &lt;/b&gt;The purpose of this study is to evaluate the safety of rivaroxaban for extended prophylaxis after major abdominal and pelvic surgery. &lt;br&gt;&lt;b&gt;Methods: &lt;/b&gt;This is a retrospective review of patients undergoing major colorectal surgery at a regional hospital in Kiev, Ukraine. Patients received peri-operative VTE prophylaxis with subcutaneous heparin and then transitioned to rivaroxaban for a total of 30 days. Occurrences of major or minor bleeding, blood transfusion, and a need for re-intervention were noted. Phone surveys were administered on post-operative day 30 to assess compliance and satisfaction with the regimen. &lt;br&gt;&lt;b&gt;Results: &lt;/b&gt;A total of 51 patients were included in the study with an average age of 62.4 years. Seventy-one percent of the cases were abdominal, 29% were pelvic cases and 59% were done laparoscopically. There was one episode of major intra-abdominal bleeding requiring return to the operating room. There were 2 minor bleeding episodes which did not require intervention. There were no VTE events in the group. The phone survey response rate was 100%. All but one patient reported having completed the full course of rivaroxaban. Patients reported that oral prophylaxis was easy to adhere to and preferable compared to injections. &lt;br&gt;&lt;b&gt;Conclusion: &lt;/b&gt;Implementation of extended prophylaxis with rivaroxaban is easy, safe and does not increase rates of postoperative bleeding.

&lt;b&gt;Introduction:&lt;/b&gt; Biological welding - controlled action of high frequency current on living tissues, which leads to their structural changes and weld formation - connection with unique biological properties (strength, high elasticity, insensitivity to microbial infection, stimulating effect on the regeneration process, speed and quality which surpasses the normal uncomplicated healing) [22]. This method is used in various fields of surgery, but at the moment there is no data on its use in case of esophageal cylindrocellular (intestinal) metaplasia (further esophageal metaplasia or Barrett's esophagus). &lt;br&gt;&lt;b&gt;Objective:&lt;/b&gt; The goal of this study is to evaluate biologic welding as a treatment option for patients with Barrett's esophagus. &lt;br&gt;&lt;b&gt;Materials and methods:&lt;/b&gt; Single-center retrospective review of patients with short-segment Barrett's esophagus and metaplasia were treated by argon plasma coagulation (APC) or Paton's welding. This was followed by Nissen fundoplication. Primary outcome of this study was mucosal healing with morphological confirmation of the absence of metaplasia. The groups included patients with a short segment of the esophagus Barrett's C2-3M3-4 (Prague Classification 2004) and high dysplasia without nodule formation in combination with hiatal hernia (VI World Congress of the International Society for Esophageal Diseases; ISED) [23-25]). &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; A total of 49 patients were included in the study with 25 patients treated by APC laser and 24 by biowelding. Four patients (16.0%) in the APC group developed stenosis and 5 patients (20.0%) developed recurrence compared to none in the biowelding group. Patients in the biowelding group had a significantly faster rate of mucosal healing leading to faster progression to Nissen fundoplication (at average 53 days) compared to APC laser group (surgery at 115 days). &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; Biological welding of Paton's is a safe and effective treatment option for patients with esophageal metaplasia.

Objective: A prior study indicated that postoperative mortality and complications were higher in geriatrics with inflammatory bowel disease (IBD). We sought to assess the rates of surgical complications and mortality in patients aged ≥65 years after colectomy for ulcerative colitis (UC)., Methods: This is a single center retrospective study at a tertiary care center. We reviewed all hospital discharges with ICD-9 code 556.X between January 2002 and January 2014. Patients were included if they underwent a colectomy for UC. All records were manually reviewed for demographics, complications and mortality within 90 days postoperatively., Results: A total of 259 patients underwent surgery for UC during the study period and 34 patients were ≥65 years old (range 65-82) at the time of their surgery. There was no difference in overall length of stay (10.5 days vs. 9.6 days; P = 0.645) or complication rates (44% vs. 47%; P = 0.854) in the ≥65 cohort compared with the under 65 cohort. Mortality was higher in the geriatric cohort but this included only two deaths within 90 days, one of which was unrelated to the surgery, compared with one death related to surgery within 90 days in the younger cohort. Readmissions occurred in 24% of both cohorts within 90 days., Conclusion: Geriatric patients undergoing surgery for UC are not at increased risk of surgery-related morbidity or mortality compared with a younger cohort.

Purpose: Although evidence suggests an inverse association between calcium intake and colorectal cancer incidence, the influence of calcium on survival after colorectal cancer diagnosis remains unclear. Experimental Design: We prospectively assessed the association of postdiagnostic calcium intake with colorectal cancer-specific and overall mortality among 1,660 nonmetastatic colorectal cancer patients within the Nurses' Health Study and the Health Professionals Follow-up Study. Patients completed a validated food frequency questionnaire between 6 months and 4 years after diagnosis and were followed up for death. Multivariable hazard ratios (HRs) and 95% confidence intervals (95% CI) were calculated using Cox proportional hazards regression., Results: Comparing the highest with the lowest quartile intake of postdiagnostic total calcium, the multivariable HRs were 0.56 (95% CI, 0.32-0.96; P trend = 0.04) for colorectal cancer-specific mortality and 0.80 (95% CI, 0.59-1.09; P trend = 0.11) for all-cause mortality. Postdiagnostic supplemental calcium intake was also inversely associated with colorectal cancer-specific mortality (HR, 0.67; 95% CI, 0.42-1.06; P trend = 0.047) and all-cause mortality (HR, 0.71; 95% CI, 0.54-0.94; P trend = 0.008), although these inverse associations were primarily observed in women. In addition, calcium from diet or dairy sources was associated with lower risk in men., Conclusions: Higher calcium intake after the diagnosis may be associated with a lower risk of death among patients with colorectal cancer. If confirmed, these findings may provide support for the nutritional recommendations of maintaining sufficient calcium intake among colorectal cancer survivors., (©2018 American Association for Cancer Research.)

Aim: Surgical site infection in colorectal surgery is associated with significant healthcare costs, which may be reduced by using a closed-incision negative-pressure therapy device. The aim of this study was to assess the impact of closed-incision negative-pressure therapy on the incidence of surgical site infection., Method: In this retrospective cohort study we evaluated all patients who had undergone high-risk open colorectal surgery at a single tertiary care centre from 2012 to 2016. We compared the incidence of surgical site infection between those receiving standard postoperative wound care between 2012 and 2014 and those receiving closed-incision negative-pressure therapy via a customizable device (Prevena Incision Management System, KCI, an Acelity company, San Antonio, Texas, USA) between 2014 and 2016. A validated surgical site infection risk score was used to create a 1:1 matched cohort subset., Results: Negative pressure therapy was used in 77 patients and compared with 238 controls. Negative pressure patients were more likely to have a stoma (92% vs 48%, P < 0.01) and to be smokers (33% vs 15%, P < 0.01). Surgical site infection was higher in control patients (15%, n = 35/238) compared with negative pressure patients (7%, n = 5/77) (P = 0.05). On regression analysis, negative pressure therapy was associated with decreased surgical site infection (OR 0.27; 95% CI 0.09-0.78). These differences persisted in the matched analysis., Conclusion: Negative pressure therapy was associated with decreased surgical site infection. Negative pressure therapy offers significant potential for quality improvement., (Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.)

Background: Retrorectal cysts make up a small but challenging group of pelvic masses, especially if they extend high into the pelvis. We present a case of successful robotic removal of a large retrorectal cyst., Methods: Video presentation of a robotic excision of a retrorectal mass., Results: We present a case of robotic removal of a large retrorectal mass extending up to the S3 vertebra., Discussion: Robotic approach is a very useful tool for successful removal of large pelvic masses that cannot be removed by traditional posterior or trans perineal approach.

Background: There is increasing public discussion about the escalating cost of healthcare in America. There are no published data regarding the contribution of individual surgeons' choices on the cost of uncomplicated minimally invasive colectomy., Methods: A review of a hospital cost-accounting database of the direct costs related to the index operation and post-operative care of all patients who underwent elective minimally invasive segmental colectomy over a 1-year period was performed., Results: A total of 111 cases were enrolled in this study, 18 of which were performed robotically. The average direct cost after minimally invasive colectomy was $5536. The cost of robotic colectomy was 53% greater than laparoscopic ($7806 vs $5096, p  < 0.001). There was no statistically significant difference in overall costs among laparoscopic cases performed by three surgeons ($5099 vs $5108 vs $5055, p  = 0.987). Average operating room supply costs among the three surgeons were $1236, $1105 and $1030, respectively ( p  = 0.067), with a standard deviation of $328 (6.4% of overall cost)., Conclusions: No significant difference in overall costs between surgeons was demonstrated despite varied training, experience levels and operative techniques. Total costs are relatively institutionally fixed and minimally influenced by variations in individual surgeon preferences.

Background Data: Currently, data regarding the rates of morbidity and mortality following non-elective colectomy for ulcerative colitis (UC) are variable. We sought to determine the rates and predictors of 90-day mortality and complications following colectomy for UC., Methods: Patients undergoing an initial surgery for UC at a tertiary care center between January 2002 and January 2014 were included. Patients were identified using ICD-9 code 556.x. Each record was manually reviewed for demographic information, medical histories, UC history, medications, and data regarding the admission and discharge. Charts were reviewed for mortality and complications within 90 days of surgery. Complications were classified using the Clavien-Dindo classification system. Univariate and multivariate analyses were performed using IBM SPSS Statistics, version 23.0., Results: Two hundred and fifty-eight patients underwent surgery for UC. 69% were elective, and 31% were urgent/emergent. There were no deaths reported within 30 days of surgery. At 90 days, there were 2 deaths in the elective group and 1 death in the urgent/emergent group. The death in the urgent/emergent group was likely related to the initial surgery, while the elective group death was not directly related to the initial surgery for UC. Complications occurred in 47% of patients. There were no significant differences in rates of complications in either surgical cohort. Majority (62%) of the complications were Clavien-Dindo grade 1 or 2 with no difference in the elective or urgent/emergent group. Unplanned readmissions occurred in 24% of cases., Conclusion: Surgery for UC is not associated with any mortality at 30 days and very low mortality at 90 days. However, surgery is associated with an increased rate of minor postoperative complications and readmissions.

Introduction: Transection of the rectum at the anorectal junction is required for proper resection in ulcerative colitis and restorative proctocolectomy. Achieving stapled transection at the pelvic floor is often challenging, particularly during laparoscopic proctectomy. Transanal mucosectomy and handsewn anastomosis are frequently used to achieve adequate resection. Rectal eversion provides an alternative for low anorectal transection and maintains the ability to perform stapled anastomosis., Technique: The purpose of this article is to describe a technique for low anorectal transection. The work was conducted at tertiary care center by 2 colon and rectal surgeons on patients undergoing total proctocolectomy with creation of ileal pouch rectal anastomosis for ulcerative colitis. We measured the ability to achieve low stapled anastomosis., Results: Very low transection was achieved, allowing for creation of IPAA without leaving significant rectal cuff. This study was limited because it is an early experience that was not performed in the setting of a scientific investigation. No sphincter or bowel functional data were obtained or evaluated., Conclusions: Rectal eversion technique provides an alternative to mucosectomy when low pelvic transection is difficult to achieve. See Video at http://links.lww.com/DCR/A441.

Purpose: Perineal wound complications associated with anorectal excision are associated with prolonged wound healing and readmission. In order to avoid these problems, the surgeon may choose to leave the anorectum in situ. The purpose of this study is to compare complications and outcomes after primary vs. delayed anorectum removal., Methods: A retrospective review of all patients undergoing proctectomy or proctocolectomy with permanent stoma between 2004 and 2014 in a single tertiary institution was conducted., Results: During the study period, we identified 117 proctectomy patients; 69 (59%) patients had anorectum removed at index operation and 41% had the anorectum left in place. Patients with retained anorectum developed pelvic abscess significantly more frequently as compared to the other group (23 vs. 4%, p = 0.003). In patients with primary anorectum removal, 22 (32%) had perineal complications and 10 (15%) required reoperations. In patients with retained anorectum, 12 patients (25%) came back for delayed perineal proctectomy at a mean time of 277 days after the index operation; 7 of those (58%) developed postoperative wound complications. There was no difference in time to perineal wound healing between primary and delayed perineal proctectomy group (154 vs. 211 days, p = 0.319)., Conclusion: Surgery involving the distal rectum is associated with a significant number of infectious perineal complications. Although leaving the anorectum in place avoids a primary perineal wound, both approaches are associated with a significant number of complications including reoperation.

Constipation is a very common complaint, with slow-transit constipation (STC) accounting for a significant proportion of cases. Old age, female gender, psychiatric illness, and history of sexual abuse are all associated with STC. The exact cause of STC remains elusive; however, multiple immune and cellular changes have been demonstrated. Diagnosis requires evidence of slowed colonic transit which may be achieved via numerous modalities. While a variety of medical therapies exist, these are often met with limited success and a minority of patients ultimately require operative intervention. When evaluating a patient with STC, it is important to determine the presence of concomitant obstructed defecation or other forms of enteric dysmotility, as this may affect treatment decisions. Although a variety of surgical procedures have been reported, subtotal colectomy with ileorectal anastomosis is the most commonly performed and well-studied procedure, with the best track record of success.

Background: The incidence of positive margins after neoadjuvant chemoradiation and adequate surgery is very low. However, when patients do present with positive or close margins, they are at a risk of local failure and local therapy options are limited. We evaluated the role of stereotactic body radiotherapy (SBRT) in patients with positive or close margins after induction chemoradiation and total mesorectal excision., Methods: This is a retrospective evaluation of patients treated with SBRT after induction chemoradiation and surgery for positive or close margins. Seven evaluable patients were included. Fiducial seeds were place at surgery. The Cyberknife(TM) system was used for planning and treatment. Patients were followed 1 month after treatment and 3-6 months thereafter. Descriptive statistics and Kaplan-Meir method was used to repot the findings., Results: Seven patients (3 men and 4 women) were included in the study with a median follow-up of 23.5 months. The median initial radiation dose was 5,040 cGy (in 28 fractions) and the median SBRT dose was 2,500 cGy (in 5 fractions). The local control at 2 years was 100%. The overall survival at 1 and 2 years was 100% and 71% respectively. There was no Grade III or IV toxicity., Conclusions: SBRT reirradiation is an effective and safe method to address positive or close margins after neoadjuvant chemoradiation and surgery for rectal cancer.

Background: Colonic obstruction is a surgical emergency, and delay in decompression results in added morbidity and mortality. Advances have led to less invasive procedures such as stenting as a bridge for definitive surgery. The aim of this article was to perform a systematic review regarding colon obstruction (malignant or benign) and to provide recommendations following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework., Methods: A systematic literature review was conducted using the PubMed, EMBASE, and the Cochrane Library databases of published studies. The search was last performed on January 2, 2015. Two independent reviewers extracted the desired variables from the studies. For our meta-analysis, we used Review Manager X.6 (RevMan). Recommendations are provided using GRADE methodology. A single POPULATION, Intervention, Comparator, Outcome (PICO) question with two outcomes was addressed as follows:, Population: in adult patients with a colonic obstruction (malignant or benign)., Intervention: should surgery be performed.Comparator: versus endoscopic stenting., Outcomes: decreased mortality and decreased emergency, nonplanned procedures?, Results: The search yielded 210 results. Screening of the titles excluded 102 articles, leaving 108 for review. After abstract review, 71 additional articles were excluded because of failure to address the PICO questions of this guideline. Thirty-seven articles were reviewed in their entirety, of those six randomized control trials that evaluated the use of stents versus emergency surgery in colonic obstruction caused by malignant disease were included in the final qualitative review., Conclusion: We conditionally recommend endoscopic, colonic stenting (if available) as initial therapy for colonic obstruction. In our review, stent use was associated with decreased mortality and rates for emergency, nonplanned procedures to include reoperations. This conditional recommendation is limited to those with malignancy because of the lack of literature supporting this practice in benign colonic disease.

Anorectal surgery is well tolerated. Rates of minor complications are relatively high, but major postoperative complications are uncommon. Prompt identification of postoperative complications is necessary to avoid significant patient morbidity. The most common acute complications include bleeding, infection, and urinary retention. Pelvic sepsis, while may result in dramatic morbidity and even mortality, is relatively rare. The most feared long-term complications include fecal incontinence, anal stenosis, and chronic pelvic pain.

Purpose: Perineal wound complications cause significant morbidity following abdominoperineal resection (APR). Myocutaneous flap closure may mitigate perineal wound complications though data is limited outside of specialized oncologic centers. We aim to compare rates of wound dehiscence in patients undergoing APR with and without flap closure., Methods: All patients undergoing APR in the National Surgical Quality Improvement Program between 2005 and 2013 were included. Thirty-day rate of wound dehiscence and other perioperative outcomes were compared between the flap and non-flap cohorts. Subgroup analysis was performed for propensity score-matched cohorts and those receiving neoadjuvant radiation., Results: Seven thousand two hundred and five patients underwent non-emergent APR [527 (7 %) flap vs. 6678 (93 %) non-flap]. Wound dehiscence occurred in 224 patients [38 (7 %) flap vs. 186 (3 %) non-flap] with 84/224 (38 %) of these reoperated. Reoperation was more common in flap patients [15 vs. 8 %; p = 0.001]. Overall morbidity was higher in flap closure [38 % flap vs. 31 % non-flap; p < 0.001]. Dehiscence was higher for flap closure in the propensity score-matched cohort [7 vs. 3 %; p < 0.001]. Flap closure was an independent predictor of dehiscence for both the overall and propensity score-matched groups. Dehiscence was not increased in patients who had neoadjuvant radiation [5.4 % flap vs. 2.6 % non-flap; p = 0.127]., Conclusions: This represents the largest study of flap vs. non-flap closure following APR and the first such study from a national database. Flap closure was independently associated with increased risk of wound dehiscence in both the overall and matched cohorts. This study highlights the challenge of wound complications following APR and provides real-world generalizable data.

Purpose: Urinary retention is a common complication of pelvic surgery, leading to urinary tract infection and prolonged hospital stays. Tamsulosin is an alpha blocker that works by relaxing bladder neck muscles. It is used to treat benign prostatic hypertrophy and retention. We aim to investigate the potential benefits of preemptive tamsulosin use on rates of urinary retention in men undergoing pelvic surgery., Methods: This is a retrospective review of an institutional colorectal database. All men undergoing pelvic surgery between 2004 and 2013 were included. Patients given 0.4 mg of tamsulosin 3 days prior and after surgery at discretion of surgeon starting in 2007 were compared with patients receiving expectant postoperative management., Results: One hundred eighty-five patients were included in the study (study group: N = 30; control group: N = 155). Study group patients were older (56.8 vs. 50.1 years). Overall urinary retention rate was 22% with significantly lower rates in the study group compared with control (6.7 vs. 25%; p = 0.029). Study group had higher rates of minimally invasive surgery (61 vs. 29.7%); however, this did not impact urinary retention rate (20.6 vs. 22.7% for minimally invasive surgery vs. open surgery; p = 0.85). Independent predictors of urinary retention included lack of preemptive tamsulosin (odds ratio (OR), 7.67; 95% confidence interval (CI), 1.4-41.7) and cancer location in the distal third of the rectum (OR, 18.8; 95% CI, 2.1-172.8)., Conclusions: Preemptive perioperative use of tamsulosin may significantly decrease the incidence of urinary retention in men undergoing pelvic surgery. This may play a role in avoidance of urinary retention, particularly in patients with distal rectal cancer.

Background: Currently, the predictors of readmission after colectomy specifically for ulcerative colitis (UC) are poorly investigated. We sought to determine the rates and predictors of 30-day readmissions after colectomy for UC., Methods: Patients undergoing total proctocolectomy and end ileostomy, abdominal colectomy with end ileostomy, proctocolectomy with ileoanal pouch anastomosis (IPAA) formation and diverting ileostomy, one stage IPAA, or abdominal colectomy with ileorectal anastomosis at a tertiary care center between January 2002 and January 2012 for UC were included. Patients were identified using ICD-9 code 556.x. Each record was manually reviewed. The electronic record system was reviewed for demographic information, medical histories, UC history, medications, and data regarding the admission and discharge. Charts were reviewed for readmissions within 30 days of surgery. Univariate and multivariate analyses were performed using Stata v.13., Results: Two hundred nine patients with UC underwent a colectomy. Forty-three percent had a proctocolectomy with IPAA and diverting ileostomy and 32% had abdominal colectomy with end ileostomy. Seventy-six percent of surgeries were due to failure of medical therapy and 68% of patients were electively admitted for surgery. Thirty-two percent (n = 67/209) of the cohort was unexpectedly readmitted within 30 days. In multivariate model, proctocolectomy with IPAA and diverting ileostomy (odds ratio [OR] = 2.11; 95% CI, 1.06-4.19; P = 0.033) was the only significant predictor of readmission. Hospital length of stay >7 days (OR = 1.82; 95% CI, 0.98-3.41; P = 0.060), presence of limited UC (OR = 2.10; 95% CI, 0.93-4.74; P = 0.074), and steroid before admission (OR = 1.69; 95% CI, 0.90-3.2; P = 0.100) trended toward significance., Conclusions: Surgery for UC is associated with a high rate of readmission. Further prospective studies are necessary to determine the means to reduce these readmissions.

Background and Objectives: When surgery is not adequate or feasible, stereotactic body radiotherapy (SBRT) reirradiation has been used for recurrent cancers. We report the outcomes of a series of patients with pelvic recurrences from colorectal cancer reirradiated with SBRT., Methods: The Cyberknife(TM) Robotic Stereotactic Radiosurgery system with fiducial based real time tracking was used. Patients were followed with imaging of the pelvis., Results: Four women and 14 men with 22 lesions were included. The mean dose was 25 Gy in median of five fractions. The mean prescription isodose was 77%, with a median maximum dose of 32.87 Gy. There were two local failures, with a crude local control rate of 89%. The median overall survival was 43 months. One patient had small bowel perforation and required surgery (Grade IV), two patients had symptomatic neuropathy (1 Grade III) and one patient developed hydronephrosis from ureteric fibrosis requiring a stent (Grade III)., Conclusions: Local recurrence in the pelvis after modern combined modality treatment for colorectal cancer is rare. However it presents a therapeutic dilemma when it occurs; often symptomatic and eventually life threatening. SBRT can be a useful non-surgical modality to control pelvic recurrences after prior radiation for colorectal cancer., (© 2015 Wiley Periodicals, Inc.)

Purpose: Surgery for hemorrhoidectomy remains a painful procedure despite advances in pain management. Gabapentin is widely used for control of acute and chronic pain. Our aim was to evaluate the effect of gabapentin on posthemorrhoidectomy pain and opioid use., Methods: A prospective, open-label study. Patients requiring hemorrhoid surgery were recruited to be in control (standard of care) or treatment group (standard of care plus daily gabapentin)., Results: Twenty-one treatment and 18 control patients were recruited. One patient from study group and two patients from control group were excluded due to failure to follow up. Pain levels for gabapentin group were significantly lower on postoperative days 1, 7, and 14 compared to the standard treatment group (3.68 vs. 6.82 p < 0.01, 2.68 vs. 5 p = 0.02 and 0.75 vs. 3.64 p < 0.001 respectively). There was a trend toward less opioids taken in gabapentin group for postoperative days 1, 7, and 14 (4.69 vs. 6.36; 2.13 vs. 2.73, and 0.125 vs. 0.9) but it did not reach statistical significance. The average hemorrhoidal grade and number of hemorrhoidal complexes removed was slightly higher in gabapentin group. Five control group patients experienced postoperative complications versus two gabapentin group patients. No gabapentin related complications were seen in the treatment group. The average cost of gabapentin course was $5.34 per patient., Conclusions: Daily use of gabapentin in perioperative period significantly decreased reported levels of postoperative pain. This effective, inexpensive addition improves pain after hemorrhoid surgery. Randomized placebo-controlled studies would better define the usefulness of this medication for posthemorrhoidectomy pain.

Advances in minimally invasive colon surgery, shown to be safe and effective, facilitated its rapid spread throughout the world. Minimally invasive rectal surgery however, has been much slower to take hold due to technical difficulty and concerns for oncologic outcomes. To date, there has been enough data accumulated to show that its similarly safe in skilled hands and leads to better patient outcomes.

Background: Minimally invasive colon surgery (MIS) has been shown to minimize pain and decrease overall recovery time. No studies have shown a clear oncologic benefit. Some literature suggests that the time to administration of chemotherapy can be important to improve outcomes for advanced colon cancer. The goal of this study is to evaluate the effect of minimally invasive surgery on the timing of chemotherapy administration., Methods: This was a retrospective review of all patients undergoing surgery for colon cancer at a tertiary institution between 2004 and 2013., Results: A total of 668 partial colectomies for cancer were performed; 241 were stage III and above and deemed appropriate for chemotherapy. Eighty-five patients did not receive chemotherapy (patient's wishes, age/comorbidities or lost to follow-up). Of the 156 patients who received chemotherapy, 57 underwent MIS and 99 had open colectomy. Average time to chemotherapy after MIS colectomy was 42.9 versus 60.3 days for open surgery (p < 0.001). In the open group, 52 (53 %) people had postoperative complications and readmissions versus 24 (39 %) in the MIS group. Postoperative complications increased the time to chemotherapy for all patients. However, among patients with complications, patients in the MIS group were still able to start chemotherapy earlier (p < 0.05) than open colectomy patients. Multivariate analysis revealed the MIS approach as the only factor lowering time between surgery and chemotherapy., Conclusions: Laparoscopic colectomy decreases the time interval from surgery to the start of chemotherapy compared with open colectomy. Postoperative complications increase the time to chemotherapy for both open and MIS surgery.

Background: Urinary tract infection is associated with increased morbidity, mortality, and healthcare costs. Colon and rectal surgery has been shown to be an independent risk factor for urinary tract infection. Decreased length of the indwelling urinary catheter may play a role in decreasing the rate of urinary tract infection., Objective: The aim of this study was to investigate the effect of standardized indwelling urinary catheter management on urinary tract infection., Design: This was a prospective cohort study., Settings: This study was conducted in an urban academic tertiary care center., Patients: All of the patients were undergoing colon or rectal resection from 2010 to 2012 at a single National Surgical Quality Improvement Program participating institution., Interventions: Intervention 1 (group 1) included implementation of a daily electronic order prompt requiring justification for an indwelling urinary catheter for >24 hours. Intervention 2 (group 2) included intervention 1 plus sterile intraoperative placement of a urinary catheter after the antiseptic preparation and draping of the patient., Main Outcome Measures: The primary outcome measured was urinary tract infection rate., Results: A total of 811 patients were identified (control = 215; group 1 = 476; group 2 = 120). Patient demographics and comorbidities were similar among the groups. No differences existed in the proportion of proctectomy among the groups. Urinary tract infection rate decreased significantly with the implementation of each intervention (control, 6.9%; group 1, 2.7%; group 2, 0.8%; p = 0.004). The lone urinary tract infection in group 2 involved ureteral reconstruction and stent placement at the time of surgery., Limitations: This study was limited by its small sample size and single institution design., Conclusions: The implementation of 2 low-cost practice interventions was associated with a statistically significant decrease in urinary tract infection in patients undergoing colorectal surgery at an academic tertiary care center.

Aim: The abdominal approach to rectal prolapse is associated with lower rates of recurrence but a higher chance of complications and has been traditionally reserved for younger patients. However, longer life expectancy and wider use of laparoscopic techniques necessitates another look at the abdominal approach in older patients., Methods: This was a retrospective review of data from patients undergoing abdominal repair of rectal prolapse between 2005 and 2011., Results: Forty-six abdominal repairs (laparoscopic or open suture rectopexy, sigmoidectomy and rectopexy and low anterior resection) were performed during the study period. Twenty-nine repairs (63%) were performed in patients under the age of 70 (average age 51) and 17 (37%) in patients older than 70 (average age 76; range 71-89). Most of the cases performed during the initial 3 years of the study were via laparotomy. However, in the last 4 years, the laparoscopic approach was used in 83% of younger patients and 69% of older patients. Average length of stay was 2.6 days for younger and 3.8 days for older patients. Both groups had similar rates of re-admission: 20% vs 23%. The rate of wound infection was higher in the younger patients (5% vs nil). However, rates of urinary tract infection, two instances (10%) vs four (30%), urinary retention, one instance (5%) vs two (15.4%), ileus, one instance (5%) vs two (15.4%) were higher in the older group., Conclusion: Wider use of laparoscopy has precipitated a change in the approach to rectal prolapse in older patients. Although associated with a slightly higher rate of post-operative complications, the abdominal approach to rectal prolapse is feasible, safe and effective in patients older than 70 years.

Background: Perioperative care of patients undergoing colon resection requires a multidisciplinary approach by the operating surgeon, residents, and nurses. Operations performed on Monday take full advantage of hospital resources throughout the week to meet expected discharge by Friday. In a current health care environment of diminishing means, improving the timing of surgery in relation to expected length of stay may play an important role in preserving health care resources., Methods: A retrospective review of a prospectively collected colorectal surgical database identified all patients who underwent segmental colon resection at a single tertiary care referral center from 2004 to 2010. Length of stay for patients undergoing elective open and minimally invasive segmental colectomy was compared for Monday versus Tuesday through the weekend. Patient and surgeon demographics were recorded as well as postoperative outcomes and complications., Results: A total of 868 segmental colectomies were performed during the study period. Length of stay was significantly decreased by .73 days (P < .01) for all segmental colectomies performed on Monday compared with those performed Tuesday through Sunday. There was also a significant decrease in length of stay looking independently at right (.96 days, P < .01) and left or sigmoid colectomies (.56 days, P < .01). There was no significant difference in patient or surgeon demographics to account for this difference., Conclusions: Segmental colectomies have a significantly decreased length in stay when performed on Monday compared with the rest of the week. The decrease is independent of surgeon, comorbidities, and complications. This difference may be the result of patients' taking full advantage of hospital resources and ancillary support. Cost-effective measures may be evaluated and directed at adjustment of resources available throughout the week to reduce length of stay., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: New ileostomates face significant physical and psychological adaptations. Despite advanced resources, such as wound, ostomy, and continence nurses, we observed a high readmission rate for dehydration among patients with new ileostomies., Objective: Our goal was to create a pathway to reduce readmission and facilitate patient education and well-being., Design: The 'Ileostomy Pathway' was established by a collaborative group at Beth Israel Deaconess Medical Center. A standardized set of patient education tools was developed to be used throughout the perioperative process. Patient's education started with the preoperative visit. All patients were directly engaged in ostomy management and trained in a stepwise progression. Patients were discharged from the hospital with flow sheets, supplies for recording intake/output, and visiting nurse services. Prospectively collected data from the first 7 months was compared with a retrospective database of the previous 4 years., Settings: This study was conducted at a tertiary academic center., Patients: Patients with a new permanent or temporary ileostomy were included., Interventions: A new ileostomy pathway was created., Main Outcome Measures: The primary outcome measured was readmission rates., Results: One hundred sixty-one patients were assigned to prepathway implementation and 42 were assigned to postpathway implementation. One hundred three of 203 (50.7%) patients were men, and 58 of 203 (28.6%) patients had permanent ostomies. Overall readmission rate was 35.4% and 21.4% for the prepathway and postpathway groups. The readmission rate for dehydration was 15.5% (25/161) for prepathway patients, but dropped to 0% in the study group. The average length of stay after creation of the new ostomy was 7.5 days and 6.6 days for prepathway and postpathway groups., Limitations: This study was limited by its small sample size and the lack of randomization., Conclusions: A simple, educational program for new ileostomy patients that includes preoperative teaching, standardized teaching materials, in-hospital engagement, observed management, and postdischarge tracking of intake and output is very effective in decreasing hospital readmission. The average length of stay remained stable, despite the addition of this teaching program to our perioperative/inpatient care.

Purpose of Review: The principles of surgical management of inflammatory bowel disease (IBD) continue to evolve with advances in medical therapy, surgical technique, and minimally invasive operative technology. The purpose of this review is to highlight such advances in colorectal and anorectal surgery for IBD over the last year., Recent Findings: Treatment of ulcerative colitis and Crohn's disease remains challenging and relies on knowledge of both medical and surgical therapies. Recent data support shorter hospitalization prior to surgical intervention in patients with acute severe ulcerative colitis, laparoscopic surgical approaches when feasible, and ciprofloxacin as optimal therapy for pouchitis, when preventive therapy with probiotics is not successful., Summary: The management of IBD remains complex and highly individualized. In severe cases, a combination of immunosuppression and surgical therapies may be required. However, the associated risks of complications make judgments about optimal treatment plans challenging.

Background: Obesity rates are rapidly growing in the developed world. While upper gastrointestinal disturbances and urinary incontinence are independently associated with obesity, the relationship between obesity and defecatory dysfunction is less well defined., Objectives: To summarize the literature on faecal incontinence, diarrhoea and constipation in obese patients and its effects of bariatric surgery., Search Strategy: A Medline search was carried out on articles published from January 1966 to March 2010., Selection Criteria: Original articles on adult obese or morbidly obese patients were identified, including results following bariatric surgery that reported faecal incontinence, diarrhoea or constipation. Other forms of pelvic floor dysfunction were excluded. Main outcome measures included faecal incontinence, diarrhoea and constipation rates and their severity in obese patients and following bariatric surgery., Results: Twenty studies reported defecatory outcomes in obese patients (n = 14) and after bariatric surgery (n = 6). While constipation rates were similar, the rates of faecal incontinence and diarrhoea were higher in obese patients compared with non-obese patients. The exact rates of these conditions, and the correlations between body mass index (BMI) and faecal incontinence, diarrhoea and constipation, were not clear. Faecal incontinence improved after Roux-en-Y gastric bypass in studies with preoperative data. The effects of bariatric surgery on diarrhoea were unclear., Conclusion: Few studies have assessed the correlations between obesity and defecatory function and the effect of bariatric surgery. Studies were often not well controlled and used non-uniform instruments to assess bowel function. Obesity appears to be correlated with higher rates of faecal incontinence and diarrhoea. The effects of bariatric surgery on these conditions are not well defined. Well-controlled studies correlating outcome with physiological pelvic floor function are needed., (© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

Muscle wasting is commonly seen in patients with hyperthyroidism and is mainly caused by stimulated muscle proteolysis. Loss of muscle mass in several catabolic conditions is associated with increased expression of the muscle-specific ubiquitin ligases atrogin-1 and MuRF1 but it is not known if atrogin-1 and MuRF1 are upregulated in hyperthyroidism. In addition, it is not known if thyroid hormone increases the activity of proteolytic mechanisms other than the ubiquitin-proteasome pathway. We tested the hypotheses that experimental hyperthyroidism in rats, induced by daily intraperitoneal injections of 100 microg/100 g body weight of triiodothyronine (T3), upregulates the expression of atrogin-1 and MuRF1 in skeletal muscle and stimulates lysosomal, including cathepsin L, calpain-, and caspase-3-dependent protein breakdown in addition to proteasome-dependent protein breakdown. Treatment of rats with T3 for 3 days resulted in an approximately twofold increase in atrogin-1 and MuRF1 mRNA levels. The same treatment increased proteasome-, cathepsin L-, and calpain-dependent proteolytic rates by approximately 40% but did not influence caspase-3-dependent proteolysis. The expression of atrogin-1 and MuRF1 remained elevated during a more prolonged period (7 days) of T3 treatment. The results provide support for a role of the ubiquitin-proteasome pathway in muscle wasting during hyperthyroidism and suggest that other proteolytic pathways as well may be activated in the hyperthyroid state., ((c) 2009 Wiley-Liss, Inc.)

Background: Inadequate fall in the intraoperative parathyroid hormone (PTH) level after removing enlarged parathyroid gland(s) typically signifies additional hyperfunctioning gland(s), prompting further neck dissection, but it may also be a false negative result. We analyzed intraoperative management of patients with an inadequate fall on PTH after excision of enlarged parathyroid gland(s)., Methods: Analysis involved a prospective database of 189 patients undergoing 193 procedures for primary hyperparathyroidism. The PTH level was determined before neck incision and 10-15 min after excision of enlarged parathyroid gland(s). A PTH decrease > 50% and into normal range was used as the criterion of successful parathyroidectomy., Results: In 48 of 193 operations, initial postexcision PTH level did not fall appropriately. That inadequate fall in PTH level was a false negative result in 16 patients (33%) and cure was achieved without additional neck exploration in all but one patient, who had additional (negative) neck exploration after excision of a parathyroid adenoma. In all patients with false negative postexcision PTH assay, operative findings concurred with preoperative imaging tests., Conclusions: Inadequate fall in intraoperative PTH may be false negative, particularly after removal of an adenoma found in the location determined by preoperative imaging. Repeat PTH may confirm the initial assay as false negative, obviating the need for additional neck dissection. Importantly, if repeat PTH does not fall appropriately, additional neck exploration needs to be performed.

Spontaneous visceral artery dissections are a rare occurrence. Here we report a case of spontaneous celiac artery dissection that was treated without surgery.

We tested the hypothesis that treatment of rats with curcumin prevents sepsis-induced muscle protein degradation. In addition, we determined the influence of curcumin on different proteolytic pathways that are activated in septic muscle (i.e., ubiquitin-proteasome-, calpain-, and cathepsin L-dependent proteolysis) and examined the role of NF-kappaB and p38/MAP kinase inactivation in curcumin-induced inhibition of muscle protein breakdown. Rats were made septic by cecal ligation and puncture or were sham-operated. Groups of rats were treated with three intraperitoneal doses (600 mg/kg) of curcumin or corresponding volumes of solvent. Protein breakdown rates were measured as release of tyrosine from incubated extensor digitorum longus muscles. Treatment with curcumin prevented sepsis-induced increase in muscle protein breakdown. Surprisingly, the upregulated expression of the ubiquitin ligases atrogin-1 and MuRF1 was not influenced by curcumin. When muscles from septic rats were treated with curcumin in vitro, proteasome-, calpain-, and cathepsin L-dependent protein breakdown rates were reduced, and nuclear NF-kappaB/p65 expression and activity as well as levels of phosphorylated (activated) p38 were decreased. Results suggest that sepsis-induced muscle proteolysis can be blocked by curcumin and that this effect may, at least in part, be caused by inhibited NF-kappaB and p38 activities. The results also suggest that there is not an absolute correlation between changes in muscle protein breakdown rates and changes in atrogin-1 and MuRF1 expression during treatment of muscle wasting.

IL-6 may exert anti-inflammatory and protective effects in intestinal mucosa and enterocytes. The influence of probiotics on mucosal and enterocyte IL-6 production is not known. We tested the hypothesis that the probiotic bacteria Lactobacillus paracasei and Lactobacillus plantarum regulate IL-6 production in intestinal epithelial cells. Cultured Caco-2 cells were treated with 1 ng/ml of IL-1beta in the absence or presence of different concentrations of L. paracasei or L. plantarum followed by measurement of IL-6 production. The role of heat shock response was examined by determining the expression of heat shock protein 70 (hsp70) and hsp27, by downregulating their expression with small interfering RNA (siRNA), or by treating cells with quercetin. Treatment of the Caco-2 cells with IL-1beta resulted in increased IL-6 production, confirming previous reports from this laboratory. Probiotics alone did not influence IL-6 production, but the addition of probitoics to IL-1beta-treated cells resulted in a substantial augmentation of IL-6 production. Treatment of the Caco-2 cells with live L. paracasei increased cellular levels of hsp70 and hsp27 and the potentiating effect on IL-6 production was inhibited by quercetin and by hsp70 or hsp27 siRNA. Results suggest that probiotics may enhance IL-6 production in enterocytes subjected to an inflammatory stimulus and that this effect may, at least in part, be heat shock dependent.