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Introduction: This study investigated the separate impacts of diet and pre-operative antibiotics on gut microbiome and colonic anastomotic healing using a mouse model., Methods: Male C57BL/6J mice were fed either low-fat-high-fibre (SD) or high-fat-low-fiber (WD) groups for 6 weeks, then further received either pre-operative antibiotics or a control sham before a colonic anastomotic procedure was performed. After 7 days, the anastomosis was assessed and microbiota composition and biodiversity were analyzed in anastomotic tissue and stool., Results: WD-fed mice had shorter survival (5.2 ​± ​2.3 vs. 6.9 ​± ​2.3 days, p ​= ​0.022), increased weight loss (5.55 ​± ​3.80g vs. 2.65 ​± ​2.36g, p ​= ​0.03), and reduced biodiversity compared to SD-fed mice. Pre-operative antibiotics improved anastomotic healing scores (1.33 ​± ​0.65 vs. 2.08 ​± ​0.79, p ​= ​0.02) and reduced Enterococcus faecalis growth in tissue and stool (p ​= ​0.02, p ​= ​0.02). Improved anastomotic healing correlated with lower Enterococcus abundance (p ​= ​0.04) and higher collagen III and IV levels (p ​= ​0.01, 0.04) in anastomotic tissue., Conclusion: SD promotes enhanced post-operative recovery and increased microbiome biodiversity, while pre-operative antibiotics enhance anastomotic healing by suppressing Enterococcus faecalis growth, mitigating collagen III/IV degradation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The mesentery has recently been implicated in the pathophysiology of Crohn's disease (CD), and several techniques have been developed to target the mesentery to reduce its influence on recurrence. We aimed to describe short-term safety and feasibility after these approaches., Methods: This is a comparative, retrospective, single-center cohort study of consecutive CD patients undergoing primary or redo ileocolic resection from 2015 to 2022 with Kono-S anastomosis (KSA), extended mesenteric excision (EME) only, or both: mesenteric excision and exclusion (MEE)., Results: 186 patients underwent KSA (n ​= ​74), EME (n ​= ​66), or MEE (n ​= ​46). The groups had comparable baseline characteristics. The MEE group operative time was longer (median: 187 vs. KSA 170, EME 152 ​min, p ​< ​0.01). Postoperatively, the groups had similar lengths of stay (median 4 days), readmissions (9.1 ​%), major postoperative complications (6.5 ​%), and anastomotic leaks (1.1 ​%)., Conclusion: Targeting the mesentery with novel surgical approaches for ileocolic Crohn's disease was safe and feasible for short-term follow-up., Competing Interests: Declaration of competing interest SDH: consulting fees, Takeda USA; research funding, Crohn's & Colitis Foundation; American Society of Colon and Rectal Surgery. The remaining authors have no disclosures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Despite the shift toward liberal primary anastomosis in penetrating colon injuries, some surgeons recommend a protective diverting ostomy (DO) proximal to the anastomosis. This study evaluates the effect of DO on outcomes in patients undergoing colon resection and anastomosis following penetrating trauma., Methods: The TQIP database (2013-2018) was queried for penetrating colon injuries undergoing colectomy and anastomosis. Patients receiving DO were propensity matched to patients without diverting ostomy (woDO) (1:3). Outcomes were compared between groups., Results: After matching, 89 DO patients were analyzed. The DO group had more surgical site infections (32 ​% vs. 21 ​%; p ​< ​0.05) and longer hospital stay (20 [13-27] vs. 15 [9-25]; p ​< ​0.05) compared to the woDO group. Mortality and unplanned operations were similar between groups., Conclusions: Diverting ostomy after colon resection and anastomosis is associated with increased infectious complications without decreasing unplanned operations or mortality. Its routine role in penetrating colon trauma needs reassessment., Competing Interests: Declaration of competing interest No author has any relevant conflicts of interest to disclose. The views presented here are the authors and do not necessarily reflect those of the United States government, the Department of Defense, or the United States Armed Forces., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury., Methods: Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R., Results: AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged., Conclusion: BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries., Competing Interests: Declaration of competing interest We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome., (Published by Elsevier Inc.)

Background: More evidence is needed on the use of NSAID based postoperative pain regimens for Crohn's disease (CD) and its association with recurrence. Our goal is to assess the impact of perioperative use of NSAIDs on endoscopic disease recurrence in patients with CD., Methods: A retrospective cohort study was conducted. The primary outcome measured was endoscopic disease recurrence within 24 months of surgery, defined as a Rutgeerts score ≥ i2., Results: We identified 107 patients with CD that underwent index ileocolectomy with primary anastomosis between January 2009 and July 2019. Endoscopic disease recurrence was identified in 28 (26.2%) and clinical recurrence in 18 (16.8%) patients. Exposure to NSAIDs did not increase 24-month endoscopic recurrence risk (22.2% vs. 38.5% patients, p = 0.12)., Conclusion: In patients with CD undergoing elective ileocolic resection and primary ileocolic anastomosis, NSAID use in the perioperative period did not impact endoscopic or clinical disease recurrence rate., (Copyright © 2022 Elsevier Inc. All rights reserved.)

BACKGROUND: Proctectomy for ulcerative colitis (UC) can be performed via intramesorectal (IME) or total mesorectal excision (TME). METHODS: We compared patient-reported bowel and sexual function among IME versus TME UC patients (September 2000 to March 2011) using the Memorial Sloan-Kettering Cancer Center Bowel Function scale, Fecal Incontinence Quality of Life, Fecal Incontinence Severity Index, Female Sexual Function Instrument, and International Index of Erectile Dysfunction surveys. RESULTS: Eighty-nine IME versus TME patients (35 ± 2 years, 57% male, 62% IME) had similar baseline characteristics, although IME patients had more open procedures (P % .03). IME patients reported better fecal continence (P = .009) but similar fecal incontinence-related quality of life (P > .44). For sexual function, there were no differences for either women (Female Sexual Function Instrument; P > .20) or men (International Index of Erectile Dysfunction; P > .22). CONCLUSIONS: IME appears to be associated with better fecal continence but no difference in overall bowel or sexual function compared with TME in patients with UC. © 2014 Elsevier Inc. All rights reserved. [ABSTRACT FROM AUTHOR]

BACKGROUND: The aim of this study was to determine factors associated with deviation in length of hospital stay (LOS) from that determined by diagnosis-related groups. METHODS: A cohort study from a prospectively collected database was conducted, including consecutive patients undergoing surgery in a high-volume colorectal surgery department in 2009. RESULTS: For 1,461 included patients, average expected and actual LOS were 8.17 days (interquartile range, 4.7 to 11.9 days) and 8.31 days (interquartile range, 4 to 10 days), respectively. The most prominent factors associated with an increase of LOS from expected were parenteral nutrition (5.11 days), emergency room admittance (3.67 days), and ileus (3.45 days) (P ≤ .001 for all). Other independently associated factors included blood transfusion, anastomotic leak, sepsis, pulmonary embolism, and surgeon. Patients with higher severity illness indexes and longer postoperative intensive care stay had lower than expected LOS. CONCLUSIONS: After colorectal surgery, several modifiable factors are associated with deviation of LOS from expected. An opportunity hence exists to reduce both LOS and financial burden for hospitals in an era of pay for performance. [ABSTRACT FROM AUTHOR]

BACKGROUND: The aim of this study was to identify unique risk factors for mortality in patients with end-stage renal disease undergoing nonemergent colorectal surgery. METHODS: A multivariate logistic regression model predicting 30-day mortality was constructed for patients with end-stage renal disease undergoing nonemergent colorectal procedures. Data were obtained from the National Surgical Quality Improvement Program (2005-2010). RESULTS: Among the 394 patients analyzed, those with serum creatinine levels >7.5 mg/dL had .07 times the adjusted mortality risk of those with levels >3.5 mg/dL. For colorectal surgery patients, the average serum creatinine level was 5.52 ± 2.6 mg/dL, and mortality was 13% (n = 50). CONCLUSIONS: High serum creatinine was associated with a lower risk for mortality in patients with end-stage renal disease, even though creatinine is often considered a risk factor for surgery. These results show how variables from a patient-centered subpopulation can differ in meaning from the general population. [ABSTRACT FROM AUTHOR]

BACKGROUND: Robotic assistance may offer unique advantages over conventional laparoscopy in colorectal operations. METHODS: This prospective observational study compared operative measures and postoperative outcomes between laparoscopic and robotic abdominal and pelvic resections for benign and malignant disease. RESULTS: From 2005 through 2012, 200 (58%) laparoscopic and 144 (42%) robotic operations were performed by a single surgeon. After adjustment for differences in demographics and disease processes using propensity score matching, all laparoscopic operations had a significantly shorter operative time (P #60;.01), laparoscopic left colectomies had a longer length of hospital stay (2009 and 2010: 6.5 vs 3.6 days, P =.01); and laparoscopic right colectomies had a higher risk for overall complications (P &#61 .03) and postoperative ileus (P &#61.04). There were no significant differences in the outcomes of pelvic operations (P =.15). CONCLUSIONS: Compared with conventional laparoscopy, some types of robotic-assisted colorectal operations may offer advantages regarding postoperative length of stay and perioperative complications. [ABSTRACT FROM AUTHOR]

BACKGROUND: The long-term prognosis of patients undergoing colectomy for fulminant Clostridium difficile colitis has not been well studied. The authors present 7-year survival trends in such patients. METHODS: Patients were identified through a pathologic database. Medical records were reviewed and follow-up phone calls made to determine relevant patient history, longevity, and quality of life. RESULTS: The 61 patients identified had mean and median survival of 18.1 and 3.2 months, respectively, and 1-year, 2-year, 5-year, and 7-year mortality of 68.5%, 79.6%, 88.9%, and 90.7%, respectively. Previous C difficile infection, hypotension, requirement of vasopressors, mental status changes, elevated arterial lactate, decreased platelet counts, intubation, and longer duration on nonoperative therapy were associated with in-hospital mortality. There were no factors correlated with longterm survival. CONCLUSIONS: Patients who require colectomy for fulminant C difficile colitis have a poor prognosis with poor long-term survival and significant morbidity. Although there are several factors associated with in-hospital mortality, there were no factors correlated with long-term survival [ABSTRACT FROM AUTHOR]

BACKGROUND: The Model for End-Stage Liver Disease Sodium Model (MELD-Na) is a validated scoring system that uses bilirubin, international normalized ratio, serum creatinine, and sodium to predict mortality in cirrhotic patients awaiting liver transplantation. The aim of this study was to identify the utility of MELD-Na to predict patient outcomes, with and without liver disease, after elective colon cancer surgery. METHODS: A review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2010) was conducted to calculate risk-adjusted 30-day outcomes using regression modeling. RESULTS: A total of 10,842 patients (mean age, 68 years; 51% women) were included. MELD-Na scores were higher in men (10.2 vs 9.1, P, .001) and in open procedures (9.9 vs 9.1, P, .001). The overall complication and mortality rates were 26.3% and 3.3%, respectively. Incremental increases in MELD-Na score correlated with a 1.2% increase in mortality and a 1.1% increase in complications. On multivariate analysis, complications increased with MELD-Na score (odds ratio [OR], 1.05 per 1 point increase; 95% confidence interval [CI], 1.038 to 1.066). MELD-Na score was also associated with increased mortality (OR, 1.13; 95% CI, 1.1 to 1.16), along with ascites (OR, 5.7; 95% CI, 3.7 to 8.8) and corticosteroids (OR, 2.1; 95% CI, 1.3 to 3.3). [ABSTRACT FROM AUTHOR]

BACKGROUND: Despite the proven benefits of laparoscopic colorectal surgery, the rate of anastomotic leaks has not changed. This study looks at the time of presentation of anastomotic leaks between laparoscopic and open colectomies. METHODS: Retrospective chart review was performed between July 2008 and 2012. Two groups were created, laparoscopic and open. The time of presentation of significant leaks requiring reoperation were compared between the groups by index colectomies. Statistical analysis is presented as paired t test and chi-square test (P < .05). RESULTS: From 1,424 segmental colectomies, the anastomotic leak rate between the two groups was not statically significant (P = .69). No difference in the time of leak detection was evident (P = .67). Mortality rate was equal between the groups. The overall complication rate of the entire cohort was statically significant (P ≤ .001). CONCLUSION: The timing of anastomotic leak detection does not differ between laparoscopy and open colorectal resections. [ABSTRACT FROM AUTHOR]

BACKGROUND: To evaluate readmissions to determine predictors and patterns of readmission. METHODS: Prospective database review identified readmitted and non-readmitted patients after colorectal surgery. Variables for the index and readmission episode were examined. RESULTS: A total of 212 readmissions and 3,292 nonreadmissions were analyzed. The majority was elective. Readmitted patients were older (P =.003), had more comorbidities (P <.0001), longer operative times (P < .0001), length of stay (P < .0001), and higher costs (P = .002). At the time of discharge, more readmitted patients required temporary nursing (P <.0001). Independent readmission predictors were higher American Society of Anesthesiologists score, previous abdominal operation, intensive care unit stay, and dysmotility/constipation surgery. At the time of readmission, 29.2% required reoperation. More than half had an open procedure initially (55.2%). After initial open procedures, reoperative time (P =.05) and LOS were longer (P =.028), and more patients required temporary nursing care at the time of discharge (P =.046). Readmissions caused an additional mean hospital cost of $12,670.89. CONCLUSIONS: Readmitted patients have distinct demographic and outcomes variables. As most were elective cases, stratifying patients preoperatively may enable perioperative planning for this higher risk group. [ABSTRACT FROM AUTHOR]

BACKGROUND: Laparoscopic colorectal surgery remains one of the most challenging techniques to learn. METHODS: The authors collected studies that have compared hand-assisted laparoscopic surgery (HALS) and open surgery for the treatment of colorectal disease over the past 17 years. Data of interest for HALS and open surgery were subjected to meta-analysis. RESULTS: Twelve studies that included 1,362 patients were studied. In total, 2.66% of HALS procedures were converted to laparotomy. Compared with the open surgery group, blood loss, rate of wound infection, and ileus in the HALS group decreased, and incision length, recovery of gastrointestinal function, and hospitalization period were shorter. There were no significant differences in operating time, hospitalization costs, mortality, and complications, including urinary tract infection, pneumonia, and anastomotic leak, between the groups. CONCLUSIONS: HALS has the advantages of minimal invasion, lower blood loss, shorter incision length, and faster recovery, and it can shorten the length of hospitalization without an increase in costs. The drawbacks are that a small number of patients who undergo HALS may need to be converted to laparotomy, and the oncologic safety and long-term prognosis are not clear. [ABSTRACT FROM AUTHOR]

BACKGROUND: Primary anastomosis with or without proximal diversion is increasingly applied to patients requiring urgent colectomy for complicated disease of the left colon. As such, the Hartmann procedure is now often restricted to patients who are unstable or otherwise poor candidates for primary anastomosis. We sought to define the complication rate of Hartmann takedown in a contemporary setting. METHODS: Consecutive adult patients undergoing colostomy takedown with colorectal anastomosis at an academic teaching hospital from January 1, 2001, to December 31, 2010, were included in the study. Complications were captured prospectively by a single trained nurse practitioner. Demographics, body mass index, American Society of Anesthesiologists (ASA) classification, interval between Hartmann procedure and subsequent takedown, surgical indication, duration of surgery, surgeon volume and specialty, length of stay, and complications were recorded. RESULTS: One hundred three patients underwent Hartmann reversal by 16 different surgeons; 7 of these surgeons performed 4 or fewer procedures during the study period. During the same time period, 334 patients underwent a Hartmann procedure at our institution. Seventy-seven of 104 patients (74%) had their index resection for complicated diverticulitis; an anastomotic leak was the second most common indication. The median age was 61 years (range 31 to 84 years), and the interval from Hartmann procedure to reversal ranged from 87 to 1,489 days. Only 8 patients (7.7%) had an ASA of 1. Thirty patients (29.1%) had postoperative complications, and 12 (11%) had 2 or more complications. There were 2 deaths and 4 anastomotic leaks, and 7 patients had inadvertent enterotomies. Only ASA status predicted postoperative complications (P = .01). CONCLUSIONS: Hartmann takedown is a morbid operation with a substantial risk of inadvertent enterotomy and serious complications. Excluding cases referred from elsewhere, there were more than 5-fold the number of Hartmann procedures than takedowns performed during the study period. This suggests that Hartmann procedures are typically restricted to patients who are also poor candidates for takedown and that their colostomy is likely to be permanent. [ABSTRACT FROM AUTHOR]

BACKGROUND: The aim of this study was to identify possible risk factors associated with chylous ascites after colorectal cancer surgery. METHODS: Patients who underwent colorectal cancer resection were enrolled in this study. Data were compared between patients who developed chylous ascites and those who did not. RESULTS: Chylous ascites was detected in 48 (6.6%) patients. There were significant differences between the groups with and without chylous ascites in terms of age (65.6 vs 61.6 years, P 5 .017), operator (5.0% vs 15.5%, P ,.001), operative procedure based on tumor location (P 5.041), operative time (206.0 vs 229.8 minutes, P 5.045), and blood loss (78.1 vs 219.7 mL, P 5.036). After subgroup analysis for right-sided colectomy and low anterior resection to compensate for the effects of the operative procedure, the differences in the operative time and blood loss were not significant. In most patients, chylous ascites was resolved with conservative management. CONCLUSIONS: Chylous ascites developed significantly more frequently in patients who underwent right-sided colectomy and in elderly patients. In addition, the incidence was also dependent on the operator. Conservative treatment was effective in most patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Computed tomography (CT) scans often identify postoperative fluid collections of uncertain clinical relevance. METHODS: Consecutive adult patients undergoing colorectal resection and postoperative CT scan from January 1, 2000 to December 31, 2008, at a university teaching hospital were identified from a prospective database. A host of clinical and CT findings were recorded. Fisher's exact test and logistic regression with univariate and multivariate analysis were used to assess the predictive value of clinical and radiologic variables. RESULTS: Nine hundred six patients had a colon resection during the study period. Fifty-four patients had a postoperative fluid collection, of which 36 were found to be abscesses. Only high clinical suspicion of an abscess predicted the presence of an abscess (P 5.009); of the radiologic criteria, only proximity to the anastomosis was predictive (P 5 .05). CONCLUSIONS: Clinical judgment is superior to radiologic and individual clinical parameters. This finding has the potential to prevent many unnecessary procedures. [ABSTRACT FROM AUTHOR]

BACKGROUND: Perioperative care of patients undergoing colon resection requires a multidisciplin-ary 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. [ABSTRACT FROM AUTHOR]

BACKGROUND: Many surgeons assume that adhesions encountered during surgery negatively influence surgical outcomes. This article attempts to assess the role adhesions have on outcomes of colon cancer surgery. METHODS: Records of 1,071 consecutive patients operated for colonic adenocarcinoma (2004-2011) were reviewed. Patients were assigned to 3 groups: no adhesions, any adhesions, or dense adhesions. Multivariate regression assessed the association between adhesions and the duration of surgery and stay as well as laparoscopic conversion and complication rates. RESULTS: Adhesions were encountered in 329 (30.7%) patients; 138(128%) had dense adhesions. After correction for age and. comorbidities, having adhesions was associated with longer surgeries (P < .001), longer hospital stays (P = .029), a borderline significantly higher conversion rate (P = .058), and a delayed return of bowel function (P = .037). Dense adhesions had stronger associations with surgical duration (P <.001), stay duration (P <.001), and conversion (P <.001). CONCLUSIONS: Abdominal adhesions independently put patients at risk for a longer and more complicated penoperative stay after colon cancer surgery. [ABSTRACT FROM AUTHOR]

BACKGROUND: Wide variation among hospitals in the rate of Clostridium difficile infection (CDI) after surgery was hypothesized to be related to different prophylactic antibiotic practices. METHODS: Between March 2008 and March 2010, 30-day confirmed postoperative CDI rates were prospectively collected for patients undergoing colectomy surgery at 23 hospitals participating in a collaborative quality improvement program. Preoperative variables significantly associated with CDI (P ≤ .10) in a bivariate analysis were incorporated into a logistic regression model to test for independent associations. RESULTS: Among 4,936 patients, the overall rate of CDI was 1.6% (range by hospital, 0%-9%). After adjusting for patient comorbidities and hospital site, type of preoperative antibiotics used for prophylaxis was not significantly associated with CDI. Emergency surgery, low albumin, and neurologic and renal comorbidities emerged as independent preoperative predictors of CDI. CONCLUSIONS: Perioperative antibiotic practices did not prove to be independently associated with CDI after colectomy surgery. [ABSTRACT FROM AUTHOR]

BACKGROUND: The purpose of this study was to determine whether surgical approach and patient demographics are important factors that influence lymph node retrieval. METHODS: This was a retrospective review of patients receiving surgical treatment for colorectal cancer at a single institution. RESULTS: Two hundred three patients underwent resection for colorectal cancer. The total number of lymph nodes recovered and the number of lymph nodes involved were similar in both the laparoscopic group and the open group. Patients who had right-sided colon resection had a higher total number of lymph nodes recovered. There was no effect of age, sex, race, or body mass index (BMI) on the total number of lymph nodes harvested or on the number of positive lymph nodes. CONCLUSIONS: Adequate regional lymphadenectomy for colorectal cancer can be successfully performed using a laparoscopic approach. Patient demographics did not make a difference in the number of total or positive lymph nodes recovered. [ABSTRACT FROM AUTHOR]

Abstract: Background: This study evaluated the incidence and risk factors for prolonged ileus in patients undergoing elective colon resection. Methods: Retrospective data were obtained in patients undergoing open colectomy with or without epidural analgesia and laparoscopic colectomy at a university-affiliated Veterans hospital. The incidence and risk factors of prolonged ileus as defined by no bowel movement before postoperative day 7 or placement of a nasogastric tube because of vomiting or abdominal distension were analyzed. Results: Incidence of prolonged ileus was 15.2%, 22.4%, and 16.7% in epidural (92 patients), nonepidural (107 patients), and laparoscopic colectomy (48 patients), respectively (P = .39). Higher age, American Society of Anesthesiologists scores, and number of comorbidities, and lower postoperative potassium level were associated with the development of prolonged ileus. Conclusions: The incidence of prolonged ileus was similar in the 3 groups studied. However, the epidural and laparoscopic groups experienced earlier return of bowel function and toleration of diet than the nonepidural group. [Copyright &y& Elsevier]

Abstract: Background: Steroid-treated patients undergoing major colorectal surgery are routinely treated with high-dose steroids (HDS) to prevent perioperative adrenal insufficiency and cardiovascular collapse. However, there is no evidence to support this practice. Methods: A retrospective analysis of 97 consecutive steroid-treated patients with inflammatory bowel disease who underwent major colorectal surgery was performed. The incidence of hemodynamic instability and surgical outcomes were compared in patients treated with perioperative low-dose steroids (LDS) versus HDS. Results: Forty-three patients were treated with HDS, and 54 patients received LDS. There was no significant difference in hemodynamic instability between HDS-treated (74%) and LDS-treated (78%) patients. No patients required rescue HDS for adrenal insufficiency. Conclusions: Steroid-treated patients with inflammatory bowel disease undergoing major colorectal surgery appear to have no clinically significant hemodynamic instability when managed with LDS versus HDS. A prospective study assessing perioperative steroid dosing in patients with inflammatory bowel disease is in progress. [Copyright &y& Elsevier]

Abstract: Background: The clinical syndrome of frailty identified through the assessment of weight loss, gait speed, grip strength, physical activity, and physical exhaustion has been used to identify patients with reduced reserves. We hypothesized that frailty is useful in predicting adverse outcomes in optimized elective elderly colorectal surgery patients. Methods: A prospective study was conducted at 2 centers (Singapore and Japan). All patients over 75 years of age undergoing colorectal resection were assessed for the presence of the syndrome of frailty. All these patients had already had their comorbidities optimized for surgery. The outcome measure was postoperative major complications (defined as Clavien-Dindo type II and above complications). Results: Eighty-three patients were studied from February 2008 to April 2010. The mean age was 81.5 years (range 75–93 years). The mean comorbidity index was 3.37 (range 0–11). Twenty-six (31.3%) patients were an American Society of Anesthesiologists (ASA) score of 3 and above. Chi-square analysis revealed that the odds ratio of postoperative major complications was 4.083 (95% confidence interval, 1.433–11.638) when the patient satisfied the criteria for frailty. Albumin <35, ASA >3, comorbidity index >5, and Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scores were not predictive of postoperative major complications. Conclusions: Preliminary findings show that frailty is a potent adjunctive tool of predicting postoperative morbidity. Frailty can be used to identify elderly patients needing further optimization before major surgery. [Copyright &y& Elsevier]

Abstract: Background: The surgical master class is a traditional method for a surgeon to learn new operations. However, there is limited evidence to support that it can help a surgeon adopt a new technique. The aim of this study was to investigate the adoption of surgical techniques after attendance at a surgical master class. Methods: A questionnaire was sent to surgeons attending surgical master classes in laparoscopic bariatric and colorectal surgery. The questionnaire examined operative experience before attending the master class and the consequent adoption of techniques. Results: There was a significant adoption of colorectal procedures, from 33% to 79% (P = .00011), and bariatric procedures, from 27% to 66% (P = .014), after attendance at the surgical master classes. Conclusions: This study shows a significant increase in surgeons'' performing advanced surgical procedures after attendance at a surgical master class. This is the first study to demonstrate the effectiveness of the master class in terms of surgeons'' adopting new techniques. [Copyright &y& Elsevier]

Abstract: Background: It is still a matter of debate as to whether palliative resection of obstructive primary tumors may prolong the survival of patients with obstructive colon cancer and unresectable synchronous metastases. The main goal of this retrospective study was to compare the use of self-expanding metallic stents (SEMS) with open surgery for the palliation of patients with respect to survival, morbidity, and the time to start chemotherapy. Methods: Between January 2000 and January 2008, 88 consecutive patients (52 who underwent surgery and 36 who underwent SEMS insertion) with obstructive colon cancer and unresectable synchronous metastases were retrospectively evaluated. Results: The median hospital stay for all admissions was 7.2 days (range, 3–29 days) in the SEMS group and 12.3 days (range, 6–45 days) in the surgery group (P = .001). The incidence of stoma formation was significantly lower in the SEMS group than in the surgery group (16.7% vs 38.5%, respectively, P = .021). The median time to starting chemotherapy was significantly shorter in patients who underwent SEMS insertion compared with those who underwent surgery (8.1 vs 21.7 days, respectively, P = .001). The 1-year and 2-year survival rates were 44.2% and 21.27% in the surgery group and 16.7% and 2.8% in the SEMS group, respectively. The median survival for all patients was 15 months from the initiation of treatment (95% confidence interval, 6.0–19 months). Conclusions: Both procedures can be safely performed, but the choice of treatment should be individualized and discussed with a multidisciplinary team. [Copyright &y& Elsevier]

Abstract: Background: Postoperative ileus is the main determinant of the length of hospital stay after colorectal surgery. Our objective was to analyze modifiable factors, including polyethylene glycol administration, associated with the return of bowel function. Methods: A retrospective review of all patients who underwent elective open partial colectomy from 2004 to 2006 at a single institution. Results: The time to the first bowel movement with and without oral intake within 48 hours postoperatively was 76 hours versus 134 hours (P < .001); with and without polyethylene glycol administration it was 73 hours versus 94 hours (P = .001); and with and without frequent ambulation it was 78 hours versus 95 hours (P = .012). With postoperative nasogastric tube drainage, the time to the first bowel movement was 22 hours longer (P = .002). Conclusions: These data confirm previous findings supporting no nasogastric tube drainage, early feeding, and frequent ambulation after colorectal surgery. Additionally, our data suggest a strong association (P = .001) between the use of polyethylene glycol and the early return of bowel function. [Copyright &y& Elsevier]

Abstract: Background: Control charts have been proposed for the measurement of quality in surgical care. Methods: For each of 181 study hospitals in the 2005 National Inpatient Sample of the Healthcare Cost and Utilization Project database, an average moving range control chart for risk-adjusted postoperative length of stay (RApoLOS) was created for patients discharged alive after elective colectomy. RApoLOS outliers using upper control limits of 2.0σ, 2.5σ, and 3.0σ were correlated to coded complications (CCs). Hospital costs were correlated to RApoLOS outliers and CCs. Results: Of 13,118 live discharges, 902 (6.9%) were outliers using a 3.0σ upper control limit, 1,350 (10.3%) were 2.5σ outliers, and 2,053 (15.7%) were 2.0σ outliers. CCs were identified in 92.7% of 3.0σ outliers, in 81.3% of 2.5σ outliers, and 70.6% of 2.0σ outliers. Increased costs were associated with RApoLOS outliers and poorly with CCs. Conclusions: Average moving range control charts for RApoLOS outliers are valid tools for measurement of surgical quality and costs. [Copyright &y& Elsevier]

Abstract: Background: Learning curves and efficiency concerns have slowed the integration of laparoscopy into colorectal practice. We evaluated our experience with laparoscopic colorectal (LC) surgery using enhanced recovery pathways (ERPs). Methods: One thousand consecutive LC procedures performed by 2 surgeons over a 5-year period using previously published, standardized ERPs were assessed. Results: The mean age was 59, and the mean body mass index was 29.5. Procedures included segmental colectomy (54%), proctectomy (19%), total colectomy (11%), ostomy (5%), and other procedures (11%). Diagnoses included malignancy (41%), diverticulitis (16%), inflammatory bowel disease (13%), and other (30%). The mean operative time was 151 minutes, and the mean blood loss was 55 mL. Conversion to an open surgery occurred in 5.8%, whereas 2.3% were performed using a hand-assist procedure. The mean hospital stay was 4.1 days (median 3), with a 6% readmission rate. Complications (20%) included mortality (0.3%), wound infection (4%), and anastomotic leak (1.4%). Conclusions: LC surgery with ERP offers excellent outcomes with efficient use of resources. [Copyright &y& Elsevier]

Abstract: Background: The need for emergent colon surgery is a common cause of severe sepsis/septic shock and mortality among surgical patients. We wanted to benchmark our outcomes against those of the National Surgical Quality Improvement Program (NSQIP). We hypothesized that having acute care surgeons to provide comprehensive perioperative care and rapid source control surgery would improve outcome. Methods: We queried the 2005 to 2007 NSQIP dataset and our prospective database for patients with severe sepsis/septic shock requiring emergency colon surgery. Demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained for all patients. Results: Both cohorts were similar with regard to age and sex. The overall mortality rate for patients in our dataset was 28.3% compared with 40.1% in the NSQIP dataset (P = .06). The average Acute Physiology and Chronic Health Evaluation II score for our patients was 31 ± 8.2 with a predicted mortality rate of 73% (P < .0001 when compared with actual mortality rate of 28.3%). Conclusions: Patients with severe sepsis/septic shock requiring emergent colon surgery have a high mortality rate. Delivery of comprehensive emergency surgical care by acute care surgeons appears to improve survival. [Copyright &y& Elsevier]

Abstract: Background: The purpose of this study was to determine the relationship of frailty and 6-month postoperative costs. Methods: Subjects aged ≥ 65 years undergoing elective colorectal operations were enrolled in a prospective observational study. Frailty was assessed by a validated measure of function, cognition, nutrition, comorbidity burden, and geriatric syndromes. Frailty was quantified by summing the number of positive characteristics in each subject. Results: Sixty subjects (mean age, 75 ± 8 years) were studied. Inpatient mortality was 2% (n = 1). Overall, 40% of subjects (n = 24) were considered nonfrail, 22% (n = 13) were prefrail, and 38% (n = 22) were frail. With advancing frailty, hospital costs increased (P < .001) and costs from discharge to 6-months increased (P < .001). Higher degrees of frailty were related to increased rates of discharge institutionalization (P < .001) and 30-day readmission (P = .044). Conclusions: A simple, brief preoperative frailty assessment accurately forecasts increased surgical hospital costs and postdischarge to 6-month healthcare costs after colorectal operations in older adults. [Copyright &y& Elsevier]

Abstract: Background: Abdominal surgery is a major oxidative stress effector. The increase in oxidative stress has been related to postoperative complications. Oxidative stress leads to the formation and accumulation of oxidation protein end products, which exhibit autofluorescence (AF) and induce inflammatory reactions. Methods: Skin AF was assessed perioperatively in 40 consecutive colorectal surgery patients until discharge. Duration of surgery, estimated blood loss, and urinary production per hour were analyzed as measures of surgical stress. The clinical occurrence of anastomotic leakage, systemic infections, and cardiopulmonary complications within 30 days of surgery were analyzed. Results: A perioperative increase in skin AF of 19 ± .2% was observed. Duration of operation and blood loss were independently associated with the perioperative increase in skin AF. Skin AF correlated with C-reactive protein levels postoperatively. American Society of Anesthesiologists classification, duration of operation, and preoperative and perioperative increases in AF were independently associated with postoperative complications. Conclusions: This is the first study to demonstrate an association between skin AF and surgical stress and outcomes, which may rate the condition of a patient after operation. [Copyright &y& Elsevier]

Abstract: Background: A previous multicenter randomized trial demonstrated that mechanical bowel preparation (MBP) does not guard against anastomotic leakage in elective colorectal surgery. The aim of this complementary study was to evaluate the effects of MBP on morbidity and mortality after anastomotic leakage in elective colorectal surgery. Methods: A subgroup analysis was performed of a randomized trial comparing the incidence of anastomotic leakage and septic complications with and without MBP in patients undergoing elective colorectal surgery. Results: Elective colorectal surgery was performed in 1,433 patients with primary anastomoses, of whom 63 patients developed anastomotic leakage. Twenty-eight patients (44%) received MBP and 35 patients (56%) did not. Mortality rate, initial need for surgical reintervention, and extent of bowel contamination did not differ between groups (29% vs 40%; P = .497, P = .667, and P = .998, respectively). Conclusions: No benefit of MBP was found regarding morbidity and mortality after anastomotic leakage in elective colorectal surgery. [Copyright &y& Elsevier]

Abstract: Background: Examination of ≥12 lymph nodes (LNs) ensures accurate staging in colon cancer. The aim of this study was to compare nodal positivity between sentinel LN mapping (SLNM) and conventional surgery in patients with <12 and ≥12 LNs harvested. Methods: From 1993 to 2008, 407 and 380 patients with colon cancer underwent SLNM and conventional surgery, respectively. Total LNs harvested and nodal positivity were analyzed. Patients were grouped according to number of LNs harvested: 2 to 11, 12 to 25, or >25. Results: The average numbers of LNs harvested in the groups with 2 to 11, 12 to 25, and >25 LNs harvested for SLNM and conventional surgery, respectively, were 8.3 and 7.1 (P < .0001), 17.2 and 16.5 (P = .09), and 34.2 and 32.1 (P = .40). Nodal positivity for SLNM and conventional surgery in the groups with <12 and ≥12 LNs harvested was 42% and 29% (P = .01) and 50% and 36% (P = .003), respectively. Overall nodal positivity was 47% for SLNM and 32% for conventional surgery (P < .0001). When SLNM with 2 to 11 LNs was compared with conventional surgery with 12 to 25 LNs, nodal positivity was 42% versus 36% (P = .35). Conclusions: SLNM possessed higher nodal positivity compared with conventional surgery. SLNM is a valuable adjunct to accurate nodal staging in colon cancer. [Copyright &y& Elsevier]

Abstract: Background: Colon preparation for elective colon resection to reduce surgical site infection (SSI) remains controversial. Methods: A review of the published literature was undertaken to define evidence-based practices for colon preparation for elective colon resection. Results: Seventy years of surgical literature has documented that mechanical bowel preparation alone does not reduce SSI. A body of clinical trials has documented the benefits of oral antibiotic bowel preparation compared with a placebo in the reduction of SSI. Clinical trials show the addition of the oral antibiotic bowel preparation to appropriate systemic preoperative preventive antibiotics provide the lowest rates of SSI. Conclusions: Mechanical bowel preparation alone does not reduce rates of SSI, but oral antibiotic preparation and systemic preoperative antibiotics are superior when compared with systemic antibiotics alone. Additional clinical trials are necessary to define the best combined overall mechanical and oral antibiotic regimen for elective colon surgery. [Copyright &y& Elsevier]

Abstract: Background: Anastomotic leakage (AL) is the most feared complication of colorectal surgery. Atherosclerosis is suggested to have a detrimental effect on anastomotic healing. This study aimed to analyze the calcium score, a measure for atherosclerosis, as a risk factor for AL. Study design: The calcium scores of colorectal patients operated on in 2 Dutch university medical centers were determined using a computed tomography scan and calcium scoring software. The aorta, common iliac arteries, internal and external iliac arteries were studied. Additionally, patient- and operation-related factors were scored. Results: A total of 122 patients were included. In patients with AL, calcium scores were significantly higher in the left common iliac artery (561.4 vs 156.0, P = .028), right common iliac artery (542.0 vs 144.4, P = .041), both common iliac arteries together (1,103.3 vs 301.9, P = .046), and the left internal iliac artery (716.3 vs 35.3, P = .044). Conclusions: Patients with higher calcium scores in the iliacal arteries have an increased leakage risk. [Copyright &y& Elsevier]

Abstract: Background: Although locoregional recurrence after rectal cancer resection has been extensively investigated, studies of salvage surgery for locoregionally recurrent colon cancer are scarce. This study aimed to determine the predictors of postsalvage survival for locoregionally recurrent colon cancer. Methods: We studied 45 consecutive patients who underwent macroscopically complete resection of locoregionally recurrent colon cancer between April 1988 and December 2007. The primary end point was cancer-specific survival, and 20 clinical variables were analyzed for their prognostic significance. Results: Cancer-specific 5-year survival for the entire cohort of 45 patients was 46%. Multivariate survival analysis showed that margin status (P = .0311), number of locoregional recurrent tumors (P = .0002), pathological grade (P = .0416), largest tumor diameter (P = .0247), and distant metastasis (P = .0006) were independently associated with cancer-specific survival. Conclusions: Salvage surgery for locoregional recurrence of colon cancer can provide a chance for long-term survival in selected patients. [Copyright &y& Elsevier]

Abstract: Background: A colorectal anastomotic leak can be life-threatening. We have assessed the feasibility of a new intraluminal biodegradable bypass device that we designed to avoid anastomotic leakage and the necessity of a temporary stoma. Methods: Fifteen patients underwent colorectal surgery. Before performing the anastomosis in a standard way, the C-Seal (Polyganics BV, Groningen, The Netherlands) was glued to the anvil of the circular stapler. Consequently, the bypass was fixated in the staple row just proximal of the simultaneously made anastomosis. A water-soluble contrast enema was performed after 1 week. Results: The sheath was well compatible with the standard stapler device and easy to use. All donuts remained intact. No radiologic or clinical leaks were observed after surgery. Conclusions: This pilot study shows that the C-Seal can be applied successfully in colorectal surgery. Further investigation with large numbers of patients is now necessary to assess the efficacy of the C-Seal as a protective device. [Copyright &y& Elsevier]

Abstract: Introduction: The aim of this study was to review the impact of age (≥75 years) on the short-term outcomes of laparoscopic colorectal surgery. Methods: Three hundred seventy-nine patients under 70 years of age and 91 patients 75 years and older were analyzed. Quantification of comorbidities was performed using the Charlson Weighted Comorbidity Index. Outcome measures were postoperative complications and 30-day mortality. Results: There was no difference in the occurrence of postoperative complications between the younger and older patients. Bivariate analysis revealed that patient age was not a risk factor of major complications (odds ratio = 1.2; 95% confidence interval, .6–2.3). Although bivariate analysis revealed that older age had a statistically significant odds ratio for 30-day mortality (odds ratio = 12.8; 95% confidence interval, 1.3–125.4), multivariate analysis revealed that it was a weighted comorbidity index score of 5 or more (P = .02) and long operative time (P = .01) that were independent predictors of 30-day mortality and not age per se. Conclusions: Age is not an independent predictor of morbidity and mortality in laparoscopic colorectal cancer surgery. [Copyright &y& Elsevier]

Abstract: Background: Small bowel obstruction (SBO) is responsible for more than 1 billion dollars in health care costs yearly in the United States. We sought to evaluate whether laparoscopic colorectal surgery resulted in a decreased incidence of SBO within the first year of surgical resection compared with open surgery. Methods: From January 2003 to December 2008, 339 patients underwent open (open colorectal resection [OPEN]) colorectal resection and 448 patients underwent laparoscopic (laparoscopic colorectal resection [LAP]) colorectal resection. Hospital admissions up to 1 year after the initial resection identified patients admitted for the management of SBO, ileus, or nausea and vomiting. Results: During the 1st year after surgery, 6 patients in the OPEN group developed SBO, and 5 patients in the LAP group developed SBO. The overall frequency of SBO for the OPEN group was 1.8% and 1.1% for the LAP group (P < .5461). Conclusions: Although advantages such as quicker postoperative recovery and decreased hospital stay have been attributed to laparoscopic surgery, no difference in the incidence of SBO within the 1st year of surgery was found compared with open colorectal surgery. [Copyright &y& Elsevier]

Abstract: Background: We evaluated the effect of a combination of fibrin sealant and topical gentamicin on a colonic anastomosis in a rat model. Methods: Partial anastomosis in the transverse colon was performed in 70 male Sprague–Dawley rats aged 6 to 10 weeks using 5 interrupted sutures. The rats were divided into 4 groups (control, gentamicin, fibrin glue, and combination). On postoperative days 3 and 5, the rats in each group were killed, anastomotic bursting pressures scores and bowel loop adhesions were determined, and histologic examination was performed. Results: No significant difference was noted in the bursting pressures, adhesions, inflammatory infiltrates, fibroblasts, or neoangiogenesis between the fibrin-glue only and the combination groups for both the day 3 and day 5 subgroups. Conclusions: The combination of topical gentamicin and fibrin glue had little effect because the combination did not provide additional anastomotic strength or decrease the number of adhesions when compared with fibrin glue alone. [Copyright &y& Elsevier]

Abstract: Background: Laparoscopic colorectal surgery (LCS) is an advanced procedure for which no objective tools exist to assess technical skill. The aim of this study was to determine expert consensus regarding items required on a rating scale for LCS, using a Delphi technique. Methods: Experts rated the substeps of LCS from 1 to 5. Responses were returned to the panel until consensus (Cronbach''s α ≥ .80) was reached. Substeps that 80% of experts rated as ≥4 were included in the final instrument. Results: Initially, α values were .81 for sigmoid colectomy, .77 for right (medial-to-lateral) colectomy, and .74 for the lateral-to-medial approach. In the second round, α values were .83 for medial-to-lateral right colectomy and .82 for lateral-to-medial colectomy. Conclusions: The Delphi method allowed the determination of consensus regarding the essential steps to be included in a tool designed to measure technical competence in LCS. [Copyright &y& Elsevier]

Abstract: Background: Inequalities in access to care have been hypothesized to be the cause of ethnic disparities in colon cancer. The aim of this study was to determine if ethnic disparities in the outcomes of colon cancer patients exist in a system with equal access. Methods: A review of 214 consecutive patients who underwent elective colon resection for adenocarcinoma at 1 institution was conducted. Statistical analysis was performed using independent t tests and χ2 tests. The Kaplan-Meier method was used for survival estimates. Results: Of the 214 patients who underwent colon cancer resection, 38% (n = 82) were African American, while 62% (n = 132) were Caucasian. There was no significant difference in the stage of disease at presentation and between the mean times from diagnosis to surgical resection for African American and Caucasian patients. Also, there were no differences in survival. Conclusion: There does not appear to be a disparity in outcomes for colon cancer patients where equal access to medical care exists. This is based on findings of equal stages at presentation, time to referral, and survival among groups. [Copyright &y& Elsevier]

Abstract: Background: Evaluation of lymph nodes is important for the optimal treatment of colon adenocarcinoma. Few studies have assessed whether lymph node harvest is compromised by obesity. We hypothesized that lymph node retrieval in colon cancer resection would be reduced in obese patients. Methods: Patients undergoing resection for colon adenocarcinoma diagnosed from 2000 to 2007 were reviewed retrospectively and stratified by body mass index (BMI). Lymph node harvest was evaluated. Results: A total of 401 patients were included. Their mean age was 72.8 years, and 44% were men. Their mean BMI was 28.2 kg/m2. Mean lymph node recovery among BMI groups was as follows: BMI less than 18.5 was 20.6; BMI of 18.5 to 24.9 was 25.1; BMI of 25 to 29.9 was 23.1; BMI of 30 to 34.9 was 22.4; BMI of 35 to 39.9 was 19.0; and BMI of 40 or greater was 21.1 nodes (P = .321). Surgical time increased with increasing BMI (P = .005). Adequacy of node harvest differed by stage (P = .007), left-sided versus right-sided resections (P = .001), and pathology technician (P = .001). Conclusions: Lymph node retrieval was not affected by BMI. [ABSTRACT FROM AUTHOR]

Abstract: Background: We performed a meta-analysis of published literature comparing the complications after open and laparoscopic elective sigmoidectomy for diverticular disease. Methods: Electronic databases were searched from January 1991 to March 2009. A systematic review was performed to obtain a summative outcome. Results: Nineteen comparative studies involving 2,383 patients were analyzed. There were 1,014 patients in the laparoscopic group and 1,369 patients in the open group. There was no significant heterogeneity among any of the complications analyzed. Patients in the laparoscopic sigmoid resection group had fewer wound infections (fixed effects model: risk ratio [RR], .54; 95% confidence interval [CI], .36–.80; z, −3.05; P < .01; random effects model: RR, .59; 95% CI, .39–.89; z, −2.54; P < .05), blood transfusions (fixed effects model: RR, .25; 95% CI, .10–.60; z, −3.10; P < .01; random effects model: RR, .28; 95% CI, .11–.68; z, −2.81; P < .01), and ileus rates (fixed effects model: RR, .37; 95% CI, .20–.66; z, −3.34; P = .001; random effects model: RR, .37; 95% CI, .20–.68; z, −3.21; P = .001) compared with open sigmoid resections. No difference was seen for medical complications, need for rehospitalization, and reoperation. Conclusions: Laparoscopic sigmoid resection is safe and has fewer postoperative surgical complications. This approach should be considered for elective cases, however, more randomized controlled trials are required to strengthen the evidence. [Copyright &y& Elsevier]

Abstract: Background: Intestinal anastomosis is a major technical component of gastrointestinal procedures. We have developed a new procedure of colonic anastomosis with a degradable stent. This article evaluates this procedure. Methods: Forty pigs were assigned randomly to a stent group (n = 20) and a control group (n = 20). A colonic anastomosis with a degradable stent was performed in the stent group, and hand-sewn anastomosis was performed in the control group. Pigs of each group were divided evenly into 4 subgroups according to time of death (days 3, 7, and 14, and month 10 postoperatively) to evaluate the healing of anastomosis. Results: All procedures were completed successfully. The surgical time of the stent group was significantly less than the control group. No complications occurred in either group. Bursting pressure of the stent group was significantly higher than the control group on postoperative days 3 and 7. No significant difference of hydroxyproline content or microvessel density was found between the 2 groups. Conclusions: The procedure of colonic anastomosis with a degradable stent is a simple, feasible, and safe procedure in this porcine model. [Copyright &y& Elsevier]

Abstract: Background: Fast-track surgery has been described as a plan to facilitate early recovery. We present one surgeon''s modifications to fast-track surgery for laparoscopic colectomy patients. Methods: We performed a retrospective review of 48 consecutive patients undergoing elective laparoscopic colectomy treated by a modified fast-track plan between 2004 and 2008. Elements included preoperative education, pre-anesthesia dexamethasone, immediate postoperative general diet, no urinary catheter, no epidural anesthesia, and no flatus or bowel movement as a discharge requirement. Data collected included the following: age, sex, body mass index, resection indications, surgical time, blood loss, pain score, time to ambulation, time to bowel function, length of stay, complications, and mortality. Results: The mean length of stay was 37 hours (1.5 d), with 29 of 48 patients discharged without passage of flatus or stool. Only 1 patient required readmission. Conclusions: Our modified fast-track plan achieved significant improvement in length of stay for laparoscopic colectomy compared with previous results. [Copyright &y& Elsevier]

Abstract: Background: The aim of this study to analyze whether ultrastaging of initially negative nonsentinel lymph nodes (non-SLNs) would increase nodal positivity in colon cancer and rectal cancer. Methods: After SLN mapping (SLNM), SLNs were ultrastaged by 4 hematoxylin and eosin and 1 immunohistochemistry sections. A blinded pathologist reexamined initially negative non-SLNs by 3 additional hematoxylin and eosin and 1 immunohistochemistry sections. Results: In 156 colon cancer and 44 rectal cancer patients, 2,755 nodes were identified (494 SLNs and 2,261 non-SLNs). Metastases were detected in 20.9% of SLNs and 8.6% of non-SLNs (P < .0001). After ultrastaging non-SLNs, only .58% became positive for metastases in 12 patients. Of these, 10 already had positive lymph nodes, hence no change of staging occurred. Ultrastaging upstaged only 2 of 200 patients (1%). Conclusions: The chance of finding additional metastases by ultrastaging of all non-SLNs is extremely low (<1%) and of little benefit. [Copyright &y& Elsevier]