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Background: The incidence of early-onset colorectal cancer (eoCRC) diagnosed among individuals under age 50 has been rising. However, risk factors for eoCRC are unclear. We investigated whether metabolic abnormalities are risk factors for eoCRC adenocarcinoma. Methods: Invasive colorectal adenocarcinoma cases diagnosed between ages 15 and 49 from 2008 to 2018 at Kaiser Permanente Southern California (KPSC) were identified. Those with a history of inflammatory bowel disease were excluded. Noncancer controls were selected 5:1 for each case matched by age, sex, and length of membership prior to index date. Data were collected from KSPC's electronic medical records. The exposures of interest included obesity, type II diabetes, hypertension, and dyslipidemia, assessed from ≥1 year prior to eoCRC diagnosis/index date. Conditional logistic regressions were used to evaluate the associations between these metabolic risk factors and risk of eoCRC adenocarcinoma, adjusting for race/ethnicity, smoking, family history, neighborhood socioeconomic status, and health care utilization. Results: A total of 1,032 cases and 5,128 controls were included. Risk of colorectal adenocarcinoma was significantly associated with obesity [odds ratio (OR) = 1.41; 95% confidence interval (CI), 1.15–1.74], but not diabetes, hypertension or dyslipidemia. In analysis stratified by tumor location, obesity was significantly associated with risk of colon adenocarcinoma OR = 1.56 (1.17–2.07), but its association with rectal adenocarcinoma was less clear OR = 1.19 (0.85–1.68). No significant interaction was detected between obesity and age (≥40 vs. Conclusions: Obesity was associated with risk for eoCRC adenocarcinoma. Impact: This finding could help inform early-onset colorectal adenocarcinoma screening and prevention recommendations. See related commentary by Hayes, p. 1775

This case report describes the novel use of ultrasound-guided MRI-fusion biopsy to sample an extraluminal perirectal mass. This is a 64-year-old man with a history of pT3N2b mucinous adenocarcinoma of the right colon with metastatic disease to the mesocolic lymph nodes. Two years after initial resection he was found on restaging CT to have a mass measuring ∼4.0 × 4.8 cm superior to the seminal vesicles. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed a moderately FDG avid soft tissue mass interposed between the prostate and the rectum. Multiparametric MRI revealed a 6.2 × 4.6 × 2.8 cm heterogeneous lobulated T2 hyperintense mass with enhancement just superior to the seminal vesicles. This mass was unable to be viewed using sigmoidoscopy. Using UroNAV technology, we were able to biopsy the mass in the clinic setting. Biopsy was confirmed as recurrent mucinous adenocarcinoma.

The treatment of rectal cancer is complex and involves specialized multidisciplinary care, although the tenet is still rooted in a high-quality total mesorectal excision. The robotic platform is one of many tools in the arsenal to assist dissection in the low pelvis. This article is a comprehensive review of the oncological outcome comparing robotic vs laparoscopic rectal cancer resection, with a particular focus on total mesorectal excision. There is no statistical difference in total mesorectal grade, circumferential margin, distal margin, and lymph node harvest. Survival data are less mature, but there is also no difference in disease-free or overall survival between the two techniques. Although additional randomized trials are still needed to validate these findings, both techniques are currently acceptable in the minimally invasive treatment of rectal cancer, and surgeon preference is paramount to safe and optimal resection.

A dynamic evolution is occurring in transanal surgery. Transanal techniques began with intraluminal surgical removal of rectal masses and have progressed to transanal total mesorectal excision (taTME) for rectal cancer. TaTME was first performed in 2009 by Sylla, Rattner, Delgado, and Lacy. This article documents the training pathway followed by pioneers in the taTME technique as well as consensus reports outlining the process of learning the taTME technique. A literature search was performed for taTME training, learning, and technique. Key elements in learning the taTME technique include appropriate indications, cadaver training, and outcomes reporting such as participating in a taTME registry. Consensus reports also agree on the following facets associated with improved outcomes: (1) appropriate case selection of mid and low rectal cancers, (2) prerequisite completion of an accredited training program in laparoscopic colorectal surgery and prior experience in transanal endoscopic surgery, (3) a two-team taTME approach from above and below is ideal, and (4) higher rectal cancer volume surgical practice. The unifying international recommendation for surgeons interested in learning the taTME technique conveys the following message: taTME is an advanced and complex technique that requires dedicated training and experience in TME surgery.

The aim of this study is to assess the incidence of incisional ventral hernia and small bowel obstruction following laparoscopic and open colorectal resection. A retrospective review was performed of a large database comprising 13 hospitals, serving 3.6 million patients in Southern California. Patients 18 years and older undergoing elective colorectal resection over a 3-year period were included. The crude incidence rates were calculated, and relative risks of ventral hernia and small bowel obstruction were determined using multivariable proportional hazard modeling. Four thousand six hundred and thirteen patients underwent 4765 colorectal resections between August 2008 and August 2011. Fifty-nine percent of the cases were performed laparoscopically; the median age was 63 years, and 49 % were males. Colorectal carcinoma (45 %) and diverticulitis (18 %) were the most common indications for surgery. The median follow-up was 2.4 years. Kaplan-Meier estimates of ventral hernia at 1, 2, and 3 years among the open cohort were significantly higher at 10.1, 17.0, and 20.5 %, compared to 5.7, 8.7, and 10.8 % in the laparoscopic cohort (p

To demonstrate the feasibility of an innovative technique for the surgical management of rectal cancer, we performed transanal minimally invasive surgery assisted low anterior resection with total mesorectal excision (TAMIS-assisted LAR with TME) in a cadaver model. Transanal LAR via natural orifice transluminal endoscopic surgery has been reported in cadaveric series using rigid transanal platforms. This procedure has not been described using a combination of a single incision laparoscopy and TAMIS transanal endoscopic platform. We describe the first cadaveric series of TAMIS-assisted LAR with TME.TAMIS-assisted LAR with TME was successfully performed in five fresh human cadavers. The procedure was performed using the mini-Gelpoint single incision platform and the Gelpoint Path TAMIS platform (Applied Medical, Rancho Santa Margarita, CA). The variables recorded were age, body mass index (BMI), operative time, complications, and specimen length. The grade of the TME was determined by evaluation of the specimen by photo documentation by a gastrointestinal pathologist.All cadavers were male with a mean age of 71 ± 8 years and mean BMI of 28 ± 3 kg/m(2). The mean operative time was 200 ± 55 min (range 128-249 min). The quality of the TME was grade I (complete) with intact mesorectum in all five cases. The mean specimen length was 36.8 ± 3.4 cm.TAMIS-assisted LAR with TME was feasible. A high-quality TME can be achieved using this innovative technique. Transanal endoscopic total mesorectal dissection may revolutionize the surgical management of rectal cancer. However, multicenter clinical trials are needed to further evaluate the oncologic safety and surgical outcomes of transanal endoscopic TME using various platforms before widespread application of this new technique.

Despite the fact that countless patients suffer from anal problems, there tends to be a lack of understanding of anal health care. Unfortunately, this leads to incorrect diagnoses and treatments. When treating a patient with an anal complaint, the primary goals are to first diagnose the etiology of the symptoms correctly, then to provide an effective and appropriate treatment strategy.The first step in this process is to take an accurate history and physical examination. Specific questions include details about bowel habits, anal hygiene, and fiber supplementation. Specific components of the physical examination include an external anal examination, a digital rectal examination, and anoscopy if appropriate.Common diagnoses include pruritus ani, anal fissures, hemorrhoids, anal abscess or fistula, fecal incontinence, and anal skin tags. However, each problem presents differently and requires a different approach for management. It is of paramount importance that the correct diagnosis is reached. Common errors include an inaccurate diagnosis of hemorrhoids when other pathology is present and subsequent treatment with a steroid product, which is harmful to the anal area.Most of these problems can be avoided by improving bowel habits. Adequate fiber intake with 30 g to 40 g daily is important for many reasons, including improving the quality of stool and preventing colorectal and anal diseases.In this Special Report, we provide an overview of commonly encountered anal problems, their presentation, initial treatment options, and recommendations for referral to specialists.

Rectoanal intussusception (RI) is a telescoping of the rectal wall during defecation. RI is an easily recognizable physiologic phenomenon on defecography. The management, however, is much more controversial. Two predominant hypotheses exist regarding the etiology of RI: RI as a primary disorder, and RI as a secondary phenomenon. The diagnosis may be suspected based on clinical symptoms of obstructive defecation. Diagnostic modalities include defecography as the gold standard. Dynamic pelvic magnetic resonance imaging (DPMRI) and transperineal ultrasound are attractive alternatives to defecography; however, their sensitivity is poor in comparison to the gold standard at this time. Management strategies including conservative measures such as biofeedback and surgical procedures including mucosal proctectomy (Delorme), rectopexy, and stapled transanal rectal resection (STARR) procedures have varied degrees of efficacy.

Small cell, neuroendocrine tumors, and melanoma of the anus are rare. Limited data exist on the incidence and management for these rare tumors. A large, prospective, population-based database was used to determine incidence and survival patterns of rare anal neoplasms. The Surveillance, Epidemiology and End Results registry was queried to identify patients diagnosed with anal canal neoplasms. Incidence and survival patterns were evaluated with respect to age, sex, race, histology, stage, and therapy. We identified 7078 cases of anal canal neoplasms: melanoma (n = 149), neuroendocrine (n = 61), and small cell neuroendocrine (n = 26). Squamous cell carcinoma (SCC) (n = 6842) served as the comparison group. Anal melanoma (AM) demonstrated the lowest survival rate at 2.5 per cent. Neuroendocrine tumors (NETs) demonstrated similar survival as SCC (10-year survival for regional disease of 25 and 22.3%, respectively). Ten-year survival of small cell NETs resembled AM (5.3 vs 2.5%). Age 60 years or older, sex, black race, stage, and surgery were independent predictors of survival. This study presents the largest patient series of rare anal neoplasms. NETs of the anal canal demonstrate similar survival patterns to SCC, whereas small cell NETs more closely resemble AM. Accurate histologic diagnosis is vital to determine treatment and surgical management because survival patterns can differ among rare anal neoplasms.

Small cell, neuroendocrine tumors, and melanoma of the anus are rare. Limited data exist on the incidence and management for these rare tumors. A large, prospective, population-based database was used to determine incidence and survival patterns of rare anal neoplasms. The Surveillance, Epidemiology and End Results registry was queried to identify patients diagnosed with anal canal neoplasms. Incidence and survival patterns were evaluated with respect to age, sex, race, histology, stage, and therapy. We identified 7078 cases of anal canal neoplasms: melanoma (n = 149), neuroendocrine (n = 61), and small cell neuroendocrine (n = 26). Squamous cell carcinoma (SCC) (n = 6842) served as the comparison group. Anal melanoma (AM) demonstrated the lowest survival rate at 2.5 per cent. Neuroendocrine tumors (NETs) demonstrated similar survival as SCC (10-year survival for regional disease of 25 and 22.3%, respectively). Ten-year survival of small cell NETs resembled AM (5.3 vs 2.5%). Age 60 years or older, sex, black race, stage, and surgery were independent predictors of survival. This study presents the largest patient series of rare anal neoplasms. NETs of the anal canal demonstrate similar survival patterns to SCC, whereas small cell NETs more closely resemble AM. Accurate histologic diagnosis is vital to determine treatment and surgical management because survival patterns can differ among rare anal neoplasms.

Ulcerative colitis is a chronic inflammatory disease of the colon; as many as 25% of patients with this disease require hospitalization. The goals of hospitalization are to assess disease severity, exclude infection, administer rapidly acting and highly effective medication regimens, and determine response. During hospitalization, patients should be given venous thromboembolism prophylaxis and monitored for the development of toxic megacolon. Patients who do not respond to intravenous corticosteroids should be considered for rescue therapy with infliximab or cyclosporine. Patients who are refractory to medical therapies or who develop toxic megacolon should be evaluated promptly for colectomy. Patients who do respond to medical therapies should be discharged on an appropriate maintenance regimen when they meet discharge criteria. We review practical evidence-based management principles and propose a day-by-day algorithm for managing patients hospitalized for ulcerative colitis.

Women make up an increasing proportion of students entering the medical profession. Before 1970, women represented 6% or less of the medical student population. In drastic contrast, nearly half of first-time applicants to medical schools in 2011 were women. However, the ratio of women to men is less balanced among graduates from surgical residencies and among leadership positions in surgery. Less than 20% of full professor, tenured faculty, and departmental head positions are currently held by women. However, this disparity may resolve with time as more women who entered the field in the 1980s emerge as mature surgeons and leaders. The aim of this article is to review the history of women in surgery and to highlight individual and institutional creative modifications that can promote the advancement of women in surgery. A secondary aim of the article is to add some levity to the discussion with personal anecdotes representing the primary author's (ECM) personal opinions, biases, and reflections.

Introduction: Apolipoprotein E (ApoE) genotype and aerobic fitness are each associated with cognitive performance in older adults. However, their potentially interactive effects on cognitive performance have not been examined. Purpose: The primary purpose of this study was to determine whether ApoE genotype and aerobic fitness interact to uniquely impact memory performance and executive functioning. A secondary purpose was to examine the interactive effects on other measures of cognition to provide a more comprehensive assessment of cognitive abilities across a broad range of functions. Methods: Community-dwelling, cognitively normal older women (N = 90) provided blood samples to allow for assessment of ApoE genotype, completed cognitive tests, and performed a maximal aerobic fitness test. Primary outcome variables were the auditory verbal learning test (AVLT), the complex figures test (CFT), and the Wisconsin card-sorting task (WCST). Secondary outcome variables were the block design test and the paced auditory serial addition task (PASAT). Results: Regression analyses indicated that aerobic fitness was associated with significantly better performance on measures of the AVLT, the CFT, and the PASAT for the ApoE-e4 homozygotes. Conclusion: The preliminary findings from this study support the possibility that aerobic fitness is positively associated with the memory performance of those individuals at most genetic risk for Alzheimer disease.

Enucleation is a technique which can be applied to benign and low grade lesions of the liver such as select neuroendocrine tumors (NET), cysts, hemangiomas and focal nodular hyperplasia. The benefits of enucleation include the preservation of maximal hepatic parenchyma, as well as the low likelihood that underlying vascular or biliary structures will be compromised. A laparoscopic approach to enucleation not only offers the benefits of minimal access surgery, but also allows simultaneous access to multiple regions of the abdomen. This may be ideal for managing certain scenarios such as the patient with distal pancreatic NET and synchronous liver metastases. Illustrative cases are shown.

Purpose : Our experience in robotic-assisted rectopexy with sigmoid colon resection (RAR+SR) or without sigmoid colon resection (RAR) was reviewed to determine if there was a significant difference in intra-operative or postoperative outcomes. Methods : We retrospectively reviewed 26 patients that underwent robotic-assisted rectopexy for rectal prolapse from 2006 to 2012. Rectopexy is performed with primary suture pexy and without mesh. Continuous variables were analyzed by t-test, while Fisher's exact test was applied for categorical data. Results : Twenty-two patients underwent RAR and 4 patients underwent RAR+SR. The average age for study participants was 56 years (range 21-78 years) and consisted of 4 men and 22 women. Recurrent rectal prolapse occurred in 2 patients at 3 and 30 months after surgery in the RAR group and no recurrence occurred in the RAR+SR group (p=1.00). The duration of surgery for RAR was 211 minutes versus 309 minutes for RAR+SR (p,0.001, CI 60.8 135.4). Intra-operative blood loss for RAR was 97.8mL compared to 87.5mL for RAR+SR (p=0.924, CI -77.4 89.7). Conversion to open procedure occurred twice with RAR and once with RAR+SR (p=0.407). Length of hospitalization averaged 3 days for RAR and 4 days for RAR+SR (p=0.196, CI -0.2 2.2). The mean follow up was 127 days (range 1-72 months). Eight of 10 patients with preoperative constipation subjectively noted improvement with RAR versus 1 of 2 patients with RAR+SR (p=0.455). Six of 10 patients with preoperative fecal incontinence had subjectively improved symptoms with RAR versus 1 of 2 patients with RAR+SR (p=1.00). Six patients in the RAR group experienced a postoperative complication (over-sedation, corneal abrasion, atrial flutter, pulmonary edema, pelvic hematoma, ileus) versus 1 complication (urinary retention) after RAR+SR (p=0.924). There were no mortalities and no complications requiring operative intervention. Conclusions : The majority of patients underwent RAR and outcomes for RAR versus RAR+SR were not significantly different in this series with the exception of increased operative time for RAR+SR. The recurrence rate was 8% and the complication rate was 27% with the majority of complications being minor complications.

Surgical resection for benign subepithelial tumors near the gastroesophageal junction is difficult, often leading to esophagectomy. Here we demonstrate the feasibility of a novel technique of dual endoscopic resection using retroflexed standard adult upper endoscope and second smaller caliber (baby) endoscope to resect benign GE junction leiomyomas (26 cm size) in four patients. Maneuvering the small caliber endoscope allowed offaxis retraction of the mass while the adult endoscope was used to carry out the dissection from the submucosal tissue. Our experience highlights the feasibility of this minimally invasive approach by enabling triangulation using endoscopic tools.

Background A novel endoscopic delivery system for infrared coagulation therapy (IRC) has been designed recently. IRC is a well-established treatment for symptomatic internal hemorrhoids. Patients frequently undergo lower endoscopy before hemorrhoid treatment to eliminate other sources of bleeding. Current treatment options are difficult to perform without an anal retractor, adequate lighting, and specialized instruments. Endoscopic IRC is an attractive alternative to standard IRC, because it can be performed during the lower endoscopy. Technique Endoscopic IRC utilizes infrared radiation generated by a control box, which is applied to the tissue through a flexible, fiber optic light guide (Precision Endoscopic Infrared Coagulator™). The light guide is placed through the colonoscope or flexible sigmoidoscope in the same chamber as other endoscopic instruments. Methods A retrospective review was performed using a prospectively collected database. A standardized protocol was utilized in all patients. Patients graded their symptoms before and after therapy by using the visual analog symptom severity scoring system (range, 0–10). These results were analyzed by using the nonparametric Wilcoxon signed-rank test. Exact P values were computed by using the R function wilcox.exact. Results A total of 55 patients underwent endoscopic IRC for predominately grade II and grade III symptomatic internal hemorrhoids (71 %). There were 22 (40 %) female patients. Posttherapy results indicated a significant improvement in global symptoms (pretreatment average global score = 2.24 vs. posttreatment average global score = 0.28; P