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Objective: To investigate fecal incontinence and defecatory, urinary, and sexual functional outcomes after transanal total mesorectal excision (taTME)., Background: Proctectomy for rectal cancer may result in alterations in defecatory, urinary, and sexual function that persist beyond 12 months. The recent multicenter phase II taTME trial demonstrated the safety of taTME in patients with stage I to III tumors., Methods: Prospectively registered self-reported questionnaires were collected from 100 taTME patients. Fecal continence [Fecal Incontinence Quality of Life (FIQL), Wexner], defecatory function [Colorectal Functional Outcome (COREFO)], urinary function (International Prostate Symptom Score), and sexual function (Female Sexual Function Index-female, International Index of Erectile Function-male) were assessed preoperatively (PQ), 3 to 4 months postileostomy closure (FQ1), and 12 to 18 months post-taTME [postoperative questionnaire 2 (FQ2)]., Results: Among 83 patients who responded at all 3 time points, FIQL, Wexner, and COREFO significantly worsened postileostomy closure. Between FQ1 and FQ2, FIQL lifestyle and coping, Wexner, and COREFO incontinence, social impact, frequency, and need for medication significantly improved, while FIQL depression and embarrassment did not change. International Prostate Symptom Score did not change relative to preoperative scores. For females, Female Sexual Function Index declined for desire, orgasm, and satisfaction between PQ and FQ1, and did not improve between FQ1 and FQ2. In males, International Index of Erectile Function declined with no change between FQ1 and FQ2., Conclusions: Although taTME resulted in initial decline in defecatory function and fecal continence, most functional domains improved by 12 months after ileostomy closure, without returning to preoperative status. Urinary function was preserved while sexual function declined without improvement by 18 months post-taTME. Our results address patient expectations and inform shared decision-making regarding taTME., Competing Interests: P.S.: consultant for Ethicon, Safeheal, Tissium, and Stryker. J.M.: consultant for Stryker, Intuitive, Medtronic; advisory board for Virtual Incision. J. Maykel: consultant for Olympus, Takeda, Safeheal, RedDress, Applied Medical. Karim Alavi: consultant for Safeheal and Olympus. K.Z.: consultant for Takeda, Intuitive, Natera. Sami Chadi: consultant for Stryker, Noah Medical. Alessio Pigazzi: Research grant from Vioptix; royalties with Xodus Medical; consultant for Medtronic and Ethicon. T.D.B.-A.: Honoraria for educational courses from Applied Medical. Matthew Albert: Research grants from Applied Medical, Stryker Endoscopy, Conmed, Human Extensions, Endoquest, Livsmed, Astellas Pharmaceuticals, Distal Motion, Proximie and Noah Medical; consultant for Applied Medical, Stryker, Distal Motion, EndoQuest, Astellas Pharmaceuticals, Livsmed and ConMed; Advisory board for Proximie and Distal Motion; stock options for Applied Medical, Proximie and Human Extensions. S.W.: Consultant for ARC/Corvus, Baxter, Becton Dickinson, GI Supply, Glaxo Smith Cline, ICON Clinical Research Limited, Intuitive Surgical, Leading BioSciences/Pallisade Bio, Livsmed, Medtronic, Olympus, Stryker, and Takeda; receives royalties from Intuitive Surgical, Karl Storz, Medtronic, Unique Surgical Innovations LLC. Stock options retained from prior consulting from CRH Medical and Intuitive Surgical. The remaining authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We aimed to compare outcomes of early and standard closure of diverting loop ileostomy (DLI) after proctectomy and determine risk factors for anastomotic leak (AL) and complications., Background: Formation of DLI has been a routine practice after proctectomy to decrease the incidence and potential adverse sequela of AL., Methods: PubMed, Scopus, and Web of Science were searched for randomized controlled trials (RCTs) that compared outcomes of early versus standard closure of DLI after proctectomy. Main outcome measures were postoperative complications, AL, ileus, surgical site infection, reoperation, readmission, and hospital stay following DLI closure., Results: Eleven RCTs (932 patients; 57% male) were included. Early closure group included 474 patients and standard closure 458 patients. Early closure was associated with higher odds of AL [odds ratio (OR): 2.315, P =0.013] and similar odds of complications (OR: 1.103, P =0.667), ileus (OR: 1.307, P =0.438), surgical site infection (OR: 1.668, P =0.079), reoperation (OR: 1.896, P =0.062), and readmission (OR: 3.431, P =0.206). Hospital stay was similar (weighted mean difference: 1.054, P =0.237). Early closure had higher odds of AL than standard closure when early closure was done ≤2 weeks (OR: 2.12, P =0.047) but not within 3 to 4 weeks (OR: 2.98, P =0.107). Factors significantly associated with complications after early closure were diabetes mellitus, smoking, and closure of DLI ≤2 weeks, whereas factors associated with AL were ≥ American Society of Anesthesiologists II classification and diabetes mellitus., Conclusions: Early closure of DLI after proctectomy has a higher risk of AL, particularly within 2 weeks of DLI formation. On the basis of this study, routine early ileostomy closure cannot be recommended., Competing Interests: S.D.W. reports receiving consulting fees from ARC/Corvus, Astellas, Baxter, Becton Dickinson, GI Supply, ICON Language Services, Intuitive Surgical, Leading BioSciences, Livsmed, Medtronic, Olympus Surgical, Stryker, Takeda and receiving royalties from Intuitive Surgical and Karl Storz Endoscopy America Inc. S.H.E. reports receiving consulting fees from SafeHeal. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess long-term outcomes of patients with perforated diverticulitis treated with resection or laparoscopic lavage (LL)., Background: Surgical treatment of perforated diverticulitis has changed in the last few decades. LL and increasing evidence that primary anastomosis (PRA) is feasible in certain patients have broadened surgical options. However, debate about the optimal surgical strategy lingers., Methods: PubMed, Scopus, and Web of Science were searched for randomized clinical trials (RCT) on surgical treatment of perforated diverticulitis from inception to October 2022. Long-term reports of RCT comparing surgical interventions for the treatment of perforated diverticulitis were selected. The main outcome measures were long-term ostomy, long-term complications, recurrence, and reintervention rates., Results: After screening 2431 studies, 5 long-term follow-up studies of RCT comprising 499 patients were included. Three studies, excluding patients with fecal peritonitis, compared LL and colonic resection, and 2 compared PRA and Hartmann procedures. LL had lower odds of long-term ostomy [odds ratio (OR) = 0.133, 95% CI: 0.278-0.579; P < 0.001] and reoperation (OR = 0.585, 95% CI: 0.365-0.937; P = 0.02) compared with colonic resection but higher odds of diverticular disease recurrence (OR = 5.8, 95% CI: 2.33-14.42; P < 0.001). Colonic resection with PRA had lower odds of long-term ostomy (OR = 0.02, 95% CI: 0.003-0.195; P < 0.001), long-term complications (OR = 0.195, 95% CI: 0.113-0.335; P < 0.001), reoperation (OR = 0.2, 95% CI: 0.108-0.384; P < 0.001), and incisional hernia (OR = 0.184, 95% CI: 0.102-0.333; P < 0.001). There was no significant difference in odds of mortality among the procedures., Conclusions: Long-term follow-up of patients who underwent emergency surgery for perforated diverticulitis showed that LL had lower odds of long-term ostomy and reoperation, but more risk for disease recurrence when compared with resection in purulent peritonitis. Colonic resection with PRA had better long-term outcomes than the Hartmann procedure for fecal peritonitis., Competing Interests: S.D.W. reports receiving consulting fees from ARC/Corvus, Astellas, Baxter, Becton Dickinson, GI Supply, ICON Language Services, Intuitive Surgical, Leading BioSciences, Livsmed, Medtronic, Olympus Surgical, Stryker, Takeda and receiving royalties from Intuitive Surgical, and Karl Storz Endoscopy America Inc. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest

Background: In recent decades, the use of near-infrared light and fluorescence-guidance during open and laparoscopic surgery has exponentially expanded across various clinical settings. However, tremendous variability exists in how it is performed., Objective: In this first published survey of international experts on fluorescence-guided surgery, we sought to identify areas of consensus and nonconsensus across 4 areas of practice: fundamentals; patient selection/preparation; technical aspects; and effectiveness and safety., Methods: A Delphi survey was conducted among 19 international experts in fluorescence-guided surgery attending a 1-day consensus meeting in Frankfurt, Germany on September 8th, 2019. Using mobile phones, experts were asked to anonymously vote over 2 rounds of voting, with 70% and 80% set as a priori thresholds for consensus and vote robustness, respectively., Results: Experts from 5 continents reached consensus on 41 of 44 statements, including strong consensus that near-infrared fluorescence-guided surgery is both effective and safe across a broad variety of clinical settings, including the localization of critical anatomical structures like vessels, detection of tumors and sentinel nodes, assessment of tissue perfusion and anastomotic leaks, delineation of segmented organs, and localization of parathyroid glands. Although the minimum and maximum safe effective dose of ICG were felt to be 1 to 2 mg and >10 mg, respectively, there was strong consensus that determining the optimum dose, concentration, route and timing of ICG administration should be an ongoing research focus., Conclusions: Although fluorescence imaging was almost unanimously perceived to be both effective and safe across a broad range of clinical settings, considerable further research remains necessary to optimize its use., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: This study aimed to determine local recurrence (LR) rate and pattern after transanal total mesorectal excision (TaTME) for rectal cancer., Background: TaTME for mid- and low rectal cancer has known a rapid and worldwide adoption. Recently, concerns have been raised on the oncological safety in light of reported high LR rates with a multifocal pattern., Methods: This was a multicenter observational cohort study in 6 tertiary referral centers. All consecutive TaTME cases for primary rectal adenocarcinoma from the first TaTME case in every center until December 2018 were included for analysis. Patients with benign tumors, malignancies other than adenocarcinoma and recurrent rectal cancer, as well as exenterative procedures, were excluded. The primary endpoint was 2-year LR rate. Secondary endpoints included patterns and treatment of LR and histopathological characteristics of the primary surgery., Results: A total of 767 patients were identified and eligible for analysis. Resection margins were involved in 8% and optimal pathological outcome (clear margins, (nearly) complete specimen, no perforation) was achieved in 86% of patients. After a median follow-up of 25.5 months, 24 patients developed LR, with an actuarial cumulative 2-year LR rate of 3% (95% CI 2-5). In none of the patients, a multifocal pattern of LR was observed. Thirteen patients had isolated LR (without systemic disease) and 10/13 could be managed by salvage surgery of whom 8 were disease-free at the end of follow-up., Conclusions and Relevance: This study shows good loco regional control after TaTME in selected cases from tertiary referral centers and does not indicate an inherent oncological risk of the surgical technique., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities., Background: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers., Methods: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting., Results: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements., Conclusions: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The wide global variation in the definition of the rectum has led to significant inconsistencies in trial recruitment, clinical management, and outcomes. Surgical technique and use of preoperative treatment for a cancer of the rectum and sigmoid colon are radically different and dependent on the local definitions employed by the clinical team. A consensus definition of the rectum is needed to standardise treatment., Methods: The consensus was conducted using the Delphi technique with multidisciplinary colorectal experts from October, 2017 to April, 2018., Results: Eleven different definitions for the rectum were used by participants in the consensus. Magnetic resonance imaging (MRI) was the most frequent modality used to define the rectum (67%), and the preferred modality for 72% of participants. The most agreed consensus landmark (56%) was "the sigmoid take-off," an anatomic, image-based definition of the junction of the mesorectum and mesocolon. In the second round, 81% of participants agreed that the sigmoid take-off as seen on computed tomography or MRI achieved consensus, and that it could be implemented in their institution. Also, 87% were satisfied with the sigmoid take-off as the consensus landmark., Conclusion: An international consensus definition for the rectum is the point of the sigmoid take-off as visualized on imaging. The sigmoid take-off can be identified as the mesocolon elongates as the ventral and horizontal course of the sigmoid on axial and sagittal views respectively on cross-sectional imaging. Routine application of this landmark during multidisciplinary team discussion for all patients will enable greater consistency in tumour localisation.

Objective: To determine the disease-free survival (DFS) and recurrence after the treatment of patients with rectal cancer with open (OPEN) or laparoscopic (LAP) resection., Background: This randomized clinical trial (ACOSOG [Alliance] Z6051), performed between 2008 and 2013, compared LAP and OPEN resection of stage II/III rectal cancer, within 12 cm of the anal verge (T1-3, N0-2, M0) in patients who received neoadjuvant chemoradiotherapy. The rectum and mesorectum were resected using open instruments for rectal dissection (included hybrid hand-assisted laparoscopic) or with laparoscopic instruments under pneumoperitoneum. The 2-year DFS and recurrence were secondary endpoints of Z6051., Methods: The DFS and recurrence were not powered, and are being assessed for superiority. Recurrence was determined at 3, 6, 9, 12, and every 6 months thereafter, using carcinoembryonic antigen, physical examination, computed tomography, and colonoscopy. In all, 486 patients were randomized to LAP (243) or OPEN (243), with 462 eligible for analysis (LAP = 240 and OPEN = 222). Median follow-up is 47.9 months., Results: The 2-year DFS was LAP 79.5% (95% confidence interval [CI] 74.4-84.9) and OPEN 83.2% (95% CI 78.3-88.3). Local and regional recurrence was 4.6% LAP and 4.5% OPEN. Distant recurrence was 14.6% LAP and 16.7% OPEN.Disease-free survival was impacted by unsuccessful resection (hazard ratio [HR] 1.87, 95% CI 1.21-2.91): composite of incomplete specimen (HR 1.65, 95% CI 0.85-3.18); positive circumferential resection margins (HR 2.31, 95% CI 1.40-3.79); positive distal margin (HR 2.53, 95% CI 1.30-3.77)., Conclusion: Laparoscopic assisted resection of rectal cancer was not found to be significantly different to OPEN resection of rectal cancer based on the outcomes of DFS and recurrence.

Objectives: To identify predictors of positive circumferential resection margin following rectal cancer resection in the United States., Background: Positive circumferential resection margin is associated with a high rate of local recurrence and poor morbidity and mortality for rectal cancer patients. Prior study has shown poor compliance with national rectal cancer guidelines, but whether this finding is reflected in patient outcomes has yet to be shown., Methods: Patients who underwent resection for stage I-III rectal cancer were identified from the 2010-2011 National Cancer Database. The primary outcome was a positive circumferential resection margin. The relationship between patient, hospital, tumor, and treatment-related characteristics was analyzed using bivariate and multivariate analysis., Results: A positive circumferential resection margin was noted in 2859 (17.2%) of the 16,619 patients included. Facility location, clinical T and N stage, histologic type, tumor size, tumor grade, lymphovascular invasion, perineural invasion, type of operation, and operative approach were significant predictors of positive circumferential resection margin on multivariable analysis. Total proctectomy had nearly a 30% increased risk of positive margin compared with partial proctectomy (OR 1.293, 95%CI 1.185-1.411) and a laparoscopic approach had nearly 22% less risk of a positive circumferential resection margin compared with an open approach (OR 0.882, 95%CI 0.790-0.985)., Conclusions: Despite advances in surgical technique and multimodality therapy, rates of positive circumferential resection margin remain high in the United States. Several tumor and treatment characteristics were identified as independent risk factors, and advances in rectal cancer care are necessary to approach the outcomes seen in other countries.

Objective: To establish a structured international expert consensus on a detailed technical description of the laparoscopic total mesorectal excision (TME)., Background: Laparoscopic TME is a common surgical approach for the treatment of rectal cancer, but there is little agreement on technical details and standards., Methods: Sixty leading surgical experts from 5 different world regions with a median overall experience of 250 laparoscopic TME participated in this study. Four stages of mixed quantitative and qualitative consensus-finding methods were applied. (1) Semistructured expert interviews were independently analyzed by 2 assessors. (2) Consensus on the interview data was reached using reiterating questionnaires (Delphi method). (3) This was further refined in an interactive workshop. (4) Based on this meeting, a comprehensive text was drafted and final approval was sought by all experts., Findings: Three theme categories were identified in 9 detailed interviews (anatomical landmarks, description of tissue retraction, and operating strategies). Following 2 rounds of a 54-item questionnaire, 29 items achieved very high agreement (A* ≥90%), 14 with good agreement (≥80%), 13 with moderate agreement (≥50%), and 18 with little or no agreement (<50%). In the workshop, areas of agreement were consolidated and conclusions were sought for those with less agreement. The final document was approved after 2 further rounds of surveys by all respondents., Conclusions: This detailed and agreed technical description of laparoscopic TME may have implications on training, assessment, quality control, and future research.

Objective: This study examines recent adherence to recommended neoadjuvant chemoradiotherapy guidelines for patients with rectal cancer across geographic regions and institution volume and assesses trends over time., Background: A recent report by the Institute of Medicine described US cancer care as chaotic. Cited deficiencies included wide variation in adherence to evidence-based guidelines even where clear consensus exists., Methods: Patients operated on for clinical stage II and III rectal cancer were selected from the 2006-2011 National Cancer Data Base. Multivariable logistic regressions were used to assess variation in chemotherapy and radiation use by cancer center type, geographical location, and hospital volume. The analysis controlled for patient age at diagnosis, sex, race/ethnicity, primary payer, average household income, average education, urban/rural classification of patient residence, comorbidity, and oncologic stage., Results: There were 30,994 patients who met the inclusion criteria. Use of neoadjuvant radiation therapy and chemotherapy varied significantly by type of cancer center. The highest rates of adherence were observed in high-volume centers compared with low-volume centers (78% vs 69%; adjusted odds ratio = 1.46; P < 0.001). This variation is mirrored by hospital geographic location. Primary payer and year of diagnosis were not predictive of rates of neoadjuvant chemoradiotherapy., Conclusions: Adherence to evidence-based treatment guidelines in rectal cancer is suboptimal in the United States, with significant differences based on hospital volume and geographic regions. Little improvement has occurred in the last 5 years. These results support the implementation of standardized care pathways and a Centers of Excellence program for US patients with rectal cancer.

Objective: To develop and evaluate an objective method of technical skills assessment for graduating subspecialists in colorectal (CR) surgery-the Colorectal Objective Structured Assessment of Technical Skill (COSATS)., Background: It may be reasonable for the public to assume that surgeons certified as competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a surgeon, is not directly assessed at the time of certification by surgical boards., Methods: A procedure-based, multistation technical skills examination was developed to reflect a sample of the range of skills necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models. Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10 graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global rating score was used as the overall examination score and a passing score was set at "borderline competent for CR practice.", Results: The global rating scale demonstrated acceptable interstation reliability (0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores effectively discriminated between CR and GS residents (P < 0.01), with 27% of the variance attributed to level of training. Nine CR residents but only 3 GS residents were deemed competent., Conclusions: The Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could be incorporated into the colorectal board examination where it would be the first attempt of a surgical specialty to formally assess technical skill at the time of certification.

Objective: To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America., Methods: A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains., Results: There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

Background: Sacral nerve stimulation has been approved for use in treating urinary incontinence in the United States since 1997, and in Europe for both urinary and fecal incontinence (FI) since 1994. The purpose of this study was to determine the safety and efficacy of sacral nerve stimulation in a large population under the rigors of Food and Drug Administration-approved investigational protocol., Methods: Candidates for SNS who provided informed consent were enrolled in this Institutional Review Board-approved multicentered prospective trial. Patients showing > or =50% improvement during test stimulation received chronic implantation of the InterStim Therapy (Medtronic; Minneapolis, MN). The primary efficacy objective was to demonstrate that > or =50% of subjects would achieve therapeutic success, defined as > or =50% reduction of incontinent episodes per week at 12 months compared with baseline., Results: A total of 133 patients underwent test stimulation with a 90% success rate, and 120 (110 females) of a mean age of 60.5 years and a mean duration of FI of 6.8 years received chronic implantation. Mean follow-up was 28 (range, 2.2-69.5) months. At 12 months, 83% of subjects achieved therapeutic success (95% confidence interval: 74%-90%; P < 0.0001), and 41% achieved 100% continence. Therapeutic success was 85% at 24 months. Incontinent episodes decreased from a mean of 9.4 per week at baseline to 1.9 at 12 months and 2.9 at 2 years. There were no reported unanticipated adverse device effects associated with InterStim Therapy., Conclusion: Sacral nerve stimulation using InterStim Therapy is a safe and effective treatment for patients with FI.

Objective: To test the hypothesis that surgeon volume would not predict short- and long-term outcomes when evaluated in the setting of technical credentialing., Summary Background Data: Surgical volume is a known predictor of outcomes; the importance of technical credentialing has not been evaluated., Methods: Fifty-three credentialed surgeons operated on 871 patients in the Clinical Outcomes of Surgical Therapy Study (NCT00002575), investigating laparoscopic versus open surgery for colon cancer. Credentialing required that each surgeon document performance of at least 20 laparoscopic colon cases and demonstrate oncologic techniques on a video-recorded case. Surgeons were separated based on volume entered into the trial (low, < or =5 cases (n = 39); medium, 6-10 cases (n = 9); or high, >10 cases (n = 5)) and compared by outcomes., Results: Patients treated by high volume compared with medium or low volume surgeons were older (70, 66, and 68 years; P < 0.001), more often had right-sided tumors (63%, 46%, and 53%; P < 0.001) and had more previous operations (48%, 38% and 45%; P < 0.004), respectively. Mean operative times were shorter (123, 147 and 145 minutes; P < 0.001), distal margins longer (13.4, 12.4 and 11.6 cm; P = 0.005), and lymph node harvest greater (14.8, 12.8, 12.6; P = 0.05) for high versus medium versus low volume surgeons. However, rates of conversion, complications, 5-year survival, and disease-free survival showed no significant differences., Conclusion: When tested in a randomized controlled trial with case-specific surgical technical credentialing and auditing, surgeon volume did not predict differences in rates of conversion, complications, or long-term cancer outcomes. Case-specific technical credentialing should be further studied specific to the role it could play in creating consistent, high quality outcomes.

Objective: To evaluate women's sexual function, self-esteem, body image, and health-related quality of life after colorectal surgery., Summary Background Data: Current literature lacks prospective studies that evaluate female sexuality/quality of life after colorectal surgery using validated instruments., Methods: Sexual function, self-esteem, body image, and general health of female patients undergoing colorectal surgery were evaluated preoperatively, at 6 and 12 months after surgery, using the Female Sexual Function Index, Rosenberg Self-Esteem scale, Body Image scale and SF-36, respectively., Results: Ninety-three women with a mean age of 43.0 +/- 11.6 years old were enrolled in the study. Fifty-seven (61.3%) patients underwent pelvic and 36 (38.7%) underwent abdominal procedures. There was a significant deterioration in overall sexual function at 6 months after surgery, with a partial recovery at 12 months (P = 0.02). Self-esteem did not change significantly after surgery. Body image improved, with slight changes at 6 months and significant improvement at 12 months, compared with baseline (P = 0.05). Similarly, mental status improved over time with significant improvement at 12 months, with values superior than baseline (P = 0.007). Physical recovery was significantly better than baseline in the first 6 months after surgery with no significant further improvement between 6 and 12 months. Overall, there were no differences between patients who had abdominal procedures and those who underwent pelvic dissection, except that patients from the former group had faster physical recovery than patients in the latter (P = 0.031). When asked about the importance of discussing sexual issues, 81.4% of the woman stated it to be extremely or somewhat important., Conclusion: Surgical treatment of colorectal diseases leads to improvement in global quality of life. There is, however, a significant decline in sexual function postoperatively. Preoperative counseling is desired by most of the patients.

Background: The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas., Material and Methods: A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral)., Results: Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1-4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohn's disease-associated fistulas successfully healed; 75% without Crohn's successfully healed.Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1-3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%., Conclusion: The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.

Objective: To assess the utility of gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula., Summary Background Data: Iatrogenic rectourethral fistula poses a rare but challenging complication of treatment for prostate cancer. A variety of procedures have been described to treat this condition, none of which has gained acceptance as the procedure of choice. The aim of this study was to review the authors' experience with gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula., Methods: A retrospective chart review of all patients who underwent gracilis muscle transposition for iatrogenic rectourethral fistula was performed, and follow-up was established by telephone interview. Successful repair was defined as absence of a fistula after reversal of fecal and urinary diversions., Results: Eleven men, mean age of 62 years, underwent 12 gracilis muscle transpositions for rectourethral fistula between 1996 and 2001. Six patients had a history of pelvic radiotherapy, and five patients had previous failed attempts to repair the fistula. In nine patients, the fistula healed following gracilis muscle transposition. One patient developed a rectocutaneous fistula that healed with fibrin glue injection, and one developed perineal sepsis requiring debridement of the transposed gracilis. This patient underwent a second gracilis transposition, which uneventfully healed. Overall, all of the patients had closure of their diverting stomas and maintained healed rectourethral fistulas. There were no intraoperative complications, and the only long-term complication of this procedure was mild medial thigh numbness in two patients., Conclusions: Gracilis muscle transposition is an effective surgical treatment for iatrogenic rectourethral fistula. It is associated with low morbidity and a high success rate.

Objective: Restorative proctocolectomy for mucosal ulcerative colitis is well established. However, the effect of age on physiologic sphincter parameters is poorly understood. Our objective was to determine whether age at the time of restorative proctocolectomy correlates with physiologic changes., Summary Background Data: In the approximately 20 years during which restorative proctocolectomy has been performed for ulcerative colitis, the indications have changed. Initially, the procedure was recommended only in patients under approximately 50 years. However, the procedure has been considered in older patients because of the increasing age of our population, the increasing frequency of recognition of patients during the "second peak" of mucosal ulcerative colitis, and the decreasing morbidity rates, due to the learning curve and to newer techniques, such as double-stapling. Few authors have presented data analyzing the effects of this operation in older patients., Methods: One hundred twenty-two patients who had undergone a two-stage restorative proctocolectomy for mucosal ulcerative colitis were divided into three groups according to age: group I (>60 years), 11 men, 6 women; group II (40-60 years), 29 men, 18 women; and group III (<40 years) 29 men, 29 women. The patients were prospectively evaluated using anal manometry and subjective functional results. Comparisons were made before surgery, after colectomy and before closure of ileostomy, and at 1 or more years after surgery., Results: There were no significant differences among the groups relative to manometric results, frequency of bowel movements, incontinence scores, or overall patient satisfaction. The postoperative mean and maximum resting pressures were significantly reduced (p < 0.001), and conversely the sensory threshold (p < 0.005) and capacity (p < 0.001) were increased in all groups up to 1 year after surgery. There were no statistically significant changes in the squeeze pressure or length of the high-pressure zone in any group at any point in time. After surgery, the mean and maximum resting pressures had returned to 80% of their original values., Conclusion: Although anorectal function is transiently somewhat impaired after restorative proctocolectomy, the impairment is not an age-related phenomenon.

Objective: The authors compared clinical bowel function and complications of a low anterior resection with either a straight or colonic J pouch anastomosis., Summary Background Data: Urgency and frequent bowel movements after rectal resection with a low anastomosis have been related to the loss of rectal reservoir function. Reconstruction with a colonic J pouch possibly can obviate some of this dysfunction. Earlier reports have been favorable, but they must be verified in randomized trials., Method: One hundred patients with rectal cancer in whom a sphincter-saving procedure was appropriate were randomized to reconstruction with either a straight or a colonic J pouch anastomosis., Results: The incidence of symptomatic anastomotic leakage was lower in the pouch group (2% vs. 15%, p = 0.03). Eighty-nine patients could be evaluated after 1 year. The pouch patients had significantly fewer bowel movements per 24 hours, and less nocturnal evacuations, urgency, and incontinence. Overall well-being owing to the bowel function was rated significantly higher by the pouch patients., Conclusion: Reconstruction with a colonic J pouch was associated with a lower incidence of anastomotic leakage and better clinical bowel function when compared with the traditional straight anastomosis. Functional superiority was especially evident during the first 2 months.

Introduction: The routine use of a nasogastric tube after elective colorectal surgery is no longer mandatory. More recently, early feeding after laparoscopic colectomy has been shown to be safe and well tolerated. Therefore, the aim of our study was to prospectively assess the safety and tolerability of early oral feeding after elective "open" abdominal colorectal operations., Materials and Methods: All patients who underwent elective laparotomy with either colon or small bowel resection between November 1992 and April 1994 were prospectively randomized to one of the following two groups: group 1: early oral feeding--all patients received a clear liquid diet on the first postoperative day followed by a regular diet as tolerated; group 2: regular feeding--all patients were treated in the "traditional" way, with feeding only after the resolution of their postoperative ileus. The nasogastric tube was removed from all patients in both groups immediately after surgery. The patients were monitored for vomiting, bowel movements, nasogastric tube reinsertion, time of regular diet consumption, complications, and length of hospitalization. The nasogastric tube was reinserted if two or more episodes of vomiting of more than 100 mL occurred in the absence of bowel movement. Ileus was considered resolved after a bowel movement in the absence of abdominal distention or vomiting., Results: One hundred sixty-one consecutive patients were studied, 80 patients in group 1 (34 males and 46 females, mean age 51 years [range 16-82 years]), and 81 patients in group 2 (43 males and 38 females, mean age 56 years [range 20-90 years]). Sixty-three patients (79%) in the early feeding group tolerated the early feeding schedule and were advanced to regular diet within the next 24 to 48 hours. There were no significant differences between the early and regular feeding groups in the rate of vomiting (21% vs. 14%), nasogastric tube reinsertion (11% vs. 10%), length of ileus (3.8 +/- 0.1 days vs. 4.1 +/- 0.1 days), length of hospitalization (6.2 +/- 0.2 days vs. 6.8 +/- 0.2 days), or overall complications (7.5% vs. 6.1%), respectively, (p = NS for all). However, the patients in the early feeding group tolerated a regular diet significantly earlier than did the patients in the regular feeding group (2.6 +/- 0.1 days vs. 5 +/- 0.1 days; p < 0.001)., Conclusion: Early oral feeding after elective colorectal surgery is safe and can be tolerated by the majority of patients. Thus, it may become a routine feature of postoperative management in these patients.