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Background: Surgery for low rectal cancer can be associated with severe bowel dysfunction and impaired quality of life. It is important to determine how patients value the trade-off between anorectal dysfunction versus abdominoperineal resection. Therefore, the objective was to determine patients' preferences for treatment for low rectal cancer., Methods: Ambulatory patients without colorectal cancer at a single high-volume academic colorectal referral center from September 2019 to March 2020 were included. Patients with prior stoma or malignancy were excluded. Participants were presented with a hypothetic scenario describing a low rectal cancer. A threshold task identified preferences for functional and oncologic outcomes for sphincter preservation versus abdominoperineal resection., Results: A total of 123 patients were recruited. Patients preferred abdominoperineal resection over sphincter preservation if there were more than a mean of 6.7 (standard deviation 4.0) daily bowel movements, 1.9 (standard deviation 2.6) daily episodes of stool incontinence, and 6.5 (standard deviation 3.2) gas incontinence. Abdominoperineal resection was preferred over sphincter preservation in 38% if daily activities were altered owing to fecal urgency. Patients were willing to accept a 10% (interquartile range, 5-25) absolute increase in risk of margin involvement with sphincter preservation to avoid abdominoperineal resection. Abdominoperineal resection was the preferred option overall for 18% of patients., Conclusion: An important proportion of patients would prefer abdominoperineal resection over sphincter preservation owing to the impairments in anorectal function associated with sphincter preservation. The decision to perform sphincter preservation or abdominoperineal resection should consider how the patients' value functional outcomes with a low anastomosis., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Current standards for lymph node harvest in colorectal cancer surgery may be inadequate. Higher lymph node yield may improve survival, but the number of lymph nodes needed to optimize survival is unknown. The objective of this study was to examine the relationship between lymph node yield and overall survival in patients undergoing colectomy for nonmetastatic colon adenocarcinoma., Methods: The 2010 to 2014 National Cancer Database was queried for patients undergoing colectomy for nonmetastatic colon adenocarcinoma. Adjusted restricted cubic splines were used to model the nonlinear relationship between lymph node harvest and overall survival. Cox proportional hazard determined independent predictors of overall survival., Results: A total of 261,423 patients were included. Restricted cubic splines demonstrated that the adjusted improvements in overall survival stabilized after 24 nodes. Patients were divided into: <12, 12 to 23, and ≥24 nodes. On survival analysis, patients with ≥24 nodes had better survival across all N stages compared to other groups (P < .001). Lymph node harvest ≥24 nodes was independently associated with improved overall survival compared to 12 to 23 nodes (hazard ratio 0.82; 95% confidence interval, 0.80-0.85)., Conclusion: Lymph node harvest ≥24 nodes is associated with improved survival in colorectal cancer patients. These data may provide indirect evidence for a more extensive lymphadenectomy for colon cancer., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Several grading schemes are available to assess surgical complications, but their relationship with patient-reported outcomes is not well understood. Therefore, our objective was to examine the effect of two complication grading schemas on health-related quality of life in colorectal surgery patients., Methods: An analysis of adult patients undergoing elective colorectal surgery from 2005 to 2013 was performed. Health-related quality of life was measured using the SF-36 preoperatively and at 4 weeks and 8 weeks postoperatively. The 30-day morbidity was classified using Clavien-Dindo grading (I-IV) and the Comprehensive Complication Index (0-100). The main outcomes were the postoperative changes in physical summary scores and mental summary scores. Multivariate logistic and fractional polynomial regression analyses were used to determine the relationship between complication severity and health-related quality of life., Results: A total of 402 patients were included in the study. Overall morbidity was 46%. Patients with complications had lower physical summary scores and mental summary scores at 4-weeks and 8-weeks postoperatively compared with patients without complications (P < .05). On multivariate regression, there was no dose-response relationship between Clavien-Dindo grade and postoperative physical summary scores and mental summary scores. Adjusted changes in the physical summary scores and mental summary scores had a more appropriate, dose-response relationship with the Comprehensive Complication Index scores., Conclusion: In patients undergoing colorectal surgery, there is a more consistent relationship between the Comprehensive Complication Index and postoperative health-related quality of life compared with the Clavien-Dindo classification., (Copyright © 2019. Published by Elsevier Inc.)

Background: The management of patients with a complete clinical response after neoadjuvant therapy for rectal adenocarcinoma is controversial. Those who advocate for resection point out the inaccuracy of N-staging with current imaging modalities. The objective of this study is to determine the impact of residual nodal involvement after complete tumor regression after neoadjuvant (chemo)radiotherapy., Methods: The 2004 to 2014 National Cancer Database was queried for patients undergoing proctectomy for nonmetastatic rectal adenocarcinoma who had received neoadjuvant (chemo)radiotherapy and with ypT0 on final pathology. Patients were grouped based on pathologic nodal stage: ypT0N- and ypT0N+. The main outcome was 5-year overall survival., Results: There were 5,156 patients with ypT0N- and 527 with ypT0N+. Mean lymph node harvest was similar (ypT0N- 12.2 nodes [standard deviation 9.1] vs ypT0N+ 11.6 nodes [standard deviation 10.3]; P = .086). Patients with ypT0N+ were more likely to have had clinically involved nodes (P < .001) and earlier clinical T-stage (P = .002). Overall survival at 5 years was less for patients with ypT0N+ (80% vs 86%, log-rank P = .014). ypT0N+ was independently associated with worse overall survival (hazard ratio 1.74, 95% confidence interval 1.33-2.28)., Conclusion: Residual nodal involvement despite complete tumor regression was associated with worse 5-year overall survival compared to complete pathologic response. Additional therapy should be considered in the presence of complete clinical tumor regression after neoadjuvant (chemo)radiotherapy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Fundoplication is performed routinely during laparoscopic repairs of a paraesophageal hernia, but the degree of fundoplication remains controversial. The purpose of this study is to assess postoperative dysphagia and reflux after a Dor versus a Nissen fundoplication in patients undergoing laparoscopic repair of giant paraesophageal hernias., Methods: We performed a retrospective cohort study of all patients undergoing laparoscopic repair of giant paraesophageal hernias with Nissen or Dor fundoplication between January 2012 and December 2017 at a high-volume center, excluding revisional and emergency cases. Primary outcomes were reflux and dysphagia at 1 and 6 months. Severe dysphagia was defined as intolerance to liquids. Balanced cohorts were created using coarsened exact matching., Results: A total of 106 patients were included, and 87 were matched (Dor = 48, Nissen = 58). Baseline characteristics were well balanced between matched groups. Mean follow-up duration was 17.7 months (standard deviation 16.4). The incidence of severe dysphagia at 1 month was less in the Dor group (0 of 48 vs 8 of 58, P = .02) with similar reflux symptoms. There was no difference in severe dysphagia and reflux symptoms at 6 months and at the latest visit., Conclusion: Dor fundoplication is associated with less severe, early postoperative dysphagia. Future studies assessing the relative importance of dysphagia and reflux on quality of life should be conducted to tailor the operative technique and optimize patient satisfaction., (Copyright © 2019 Elsevier Inc. All rights reserved.)