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Background and Objectives: The routine use of preoperative bowel preparation (BP) is heavily debated in the colorectal surgery literature. To date, no study has investigated the effect preoperative BP has on patients with an established anastomotic leak. We therefore seek to compare the severity of patient morbidity and mortality in patients with a known anastomotic leak based on type of preoperative BP using the Targeted Colectomy American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP)., Methods: All elective colon cancer operations performed with primary anastomosis were identified within the targeted colectomy database from 2012 to 2013. Patients who experienced a postoperative anastomotic leak were identified and stratified based on preoperative BP. Variables that had an association with mechanical BP at P < 0.10 were included in a multivariate logistic regression model to determine if BP was independently associated with postoperative morbidity and mortality., Results: A total of 6,297 patients underwent elective colon resection with primary anastomosis for colon cancer. Two hundred and nineteen (3.5%) patients experienced an anastomotic leak. Thirty-day wound morbidity and mortality was not worse in patients who underwent preoperative BP., Conclusions: BP is not associated with worse patients outcomes in those patients with an established anastomotic leak following elective colon research with primary anastomosis. J. Surg. Oncol. 2016;114:810-813. © 2016 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background and Objectives: Guidelines on the management of colon cancer state that extensive colectomy should be "considered" for patients of young age (<50). This study aimed to compare the risk of metachronous cancer, overall recurrence and mortality between segmental and extended colon resections in patients under the age of 50 with sporadic CRC., Methods: We performed a retrospective review of patients age <50 undergoing surgery for CRC from 1991 to 2009. Patients were divided into two groups based on extent of resection: segmental versus extended. The primary outcomes analyzed were metachronous tumors, disease recurrence, and overall survival., Results: Two hundred seventy one patients underwent segmental resection and 30 underwent extended resection. 3.3% in the segmental resection group developed metachronous CRC versus 0% in the extended resection group (P = 0.61). There was no significant difference in the risk of recurrence or mortality for those who underwent a segmental resection compared to those with an extended resection. In a regression model, type of surgery was not an independent risk factor for recurrence or mortality., Conclusions: Extended colectomy for sporadic CRC in patients younger than 50 does not improve disease-free or overall survival. Further study to determine if segmental resection is appropriate oncologic treatment is warranted., (© 2014 Wiley Periodicals, Inc.)

Background: The Accordion severity grading system is a novel system to score the severity of postoperative complications in a standardized fashion. This study aims to demonstrate the validity of the Accordion system in colorectal surgery by correlating severity grades with short-term outcomes after right colectomy for colon cancer., Methods: This is a retrospective cohort review of patients who underwent right colectomy for cancer between January 1, 2002, and January 31, 2007, at a single tertiary care referral center. Complications were categorized according to the Accordion severity grading system: grades 1 (mild), 2 (moderate), 3-5 (severe), and 6 (death). Outcome measures were hospital stay, 30-d readmission rate and 1-y survival. Correlation between Accordion grades and outcome measures is reflected by Spearman rho (ρ). One-year survival was obtained per Kaplan-Meier method and compared by logrank test for trend. Significance was set at P ≤ 0.05., Results: Overall, 235 patients underwent right colectomy for cancer of which 122 (51.9%) had complications. In total, 52 (43%) had an Accordion grade 1 complication; 44 (36%) grade 2; four (3%) grade 3; 11 (9%) grade 4; seven (6%) grade 5; and four (3%) grade 6. There was significant correlation between Accordion grades and hospital stay (ρ = 0.495, P < 0.001) and 30-d readmission rate (ρ = 0.335, P < 0.001). There was a significant downward trend in 1-y survival as complication severity by Accordion grade increased (P = 0.02)., Conclusions: The Accordion grading system is a useful tool to estimate short-term outcomes after right colectomy for cancer. High-grade Accordion complications are associated with longer hospital stay and increased risk of readmission and mortality., (Published by Elsevier Inc.)

Background: Laparoscopic rectal cancer surgery has limited short-term benefits in comparison with open surgery. Long-term measures of recovery are needed., Objective: The aim of this study was to assess the impact of surgical approach (laparoscopic vs open) for the treatment of rectal cancer on the time to postoperative chemotherapy., Design: This study is a retrospective review of 150 patients who underwent low anterior resection and received postoperative chemotherapy between 2005 and 2011., Settings: This study was conducted at a tertiary care hospital., Patients: One hundred fifty patients who had stage II or III rectal cancer who underwent low anterior resection were selected. All patients received postoperative chemotherapy, the timing of which was at the discretion of the oncologist., Main Outcome Measures: Patient demographics, clinicopathologic variables, and time to postoperative chemotherapy were compared. Multivariate analysis was performed to identify variables affecting the time to postoperative chemotherapy., Results: There were no differences in clinicopathologic variables between cohorts including age, BMI, sex, ASA score, diverting ileostomy, preoperative radiotherapy, or pathologic stage. Univariate analysis demonstrated differences in intraoperative blood loss (300 vs 448 mL, p < 0.01), length of stay (7.6 vs 8.9 days, p < 0.05), wound infection (12.0 vs 24.0%, p < 0.05), and tumor location (8.0 vs 6.9 cm, p < 0.05) for laparoscopic vs open patients. There were more complications in the open vs laparoscopic group (47 vs 24, p < 0.001); however, the percentage of patients experiencing complications in the open vs laparoscopic cohorts did not reach statistical significance (32.0 vs 18.7%, p = 0.09). A decrease in mean time to postoperative chemotherapy was found for patients undergoing laparoscopic vs open surgery (50.1 vs 75.2 days, p < 0.0001). Multivariate analysis demonstrated that the approach of surgery was an independent predictor of time to postoperative chemotherapy (p < 0.01)., Limitations: This study was limited by its retrospective design and selection bias., Conclusions: In selected patients, patients undergoing laparoscopic rectal cancer surgery receive postoperative chemotherapy 25 days earlier than patients undergoing open surgery. Time to postoperative chemotherapy serves as an outcome measure for improved recovery in laparoscopic rectal cancer surgery.

Background: Despite the routine use of prophylactic systemic antibiotics, surgical-site infection continues to be associated with significant morbidity and cost after colorectal surgery. The gentamicin-collagen sponge, an implantable topical antibiotic agent, is approved for surgical implantation in 54 countries. Since 1985, more than 1 million patients have been treated with the sponges., Methods: In a phase 3 trial, we randomly assigned 602 patients undergoing open or laparoscopically assisted colorectal surgery at 39 U.S. sites to undergo either the insertion of two gentamicin-collagen sponges above the fascia at the time of surgical closure (the sponge group) or no intervention (the control group). All patients received standard care, including prophylactic systemic antibiotics. The primary end point was surgical-site infection occurring within 60 days after surgery, as adjudicated by a clinical-events classification committee that was unaware of the study-group assignments., Results: The incidence of surgical-site infection was higher in the sponge group (90 of 300 patients [30.0%]) than in the control group (63 of 302 patients [20.9%], P=0.01). Superficial surgical-site infection occurred in 20.3% of patients in the sponge group and 13.6% of patients in the control group (P=0.03), and deep surgical-site infection in 8.3% and 6.0% (P=0.26), respectively. Patients in the sponge group were more likely to visit an emergency room or surgeon's office owing to a wound-related sign or symptom (19.7%, vs. 11.0% in the control group; P=0.004) and to be rehospitalized for surgical-site infection (7.0% vs. 4.3%, P=0.15). The frequency of adverse events did not differ significantly between the two groups., Conclusions: Our large, multicenter trial shows that the gentamicin-collagen sponge is not effective at preventing surgical-site infection in patients who undergo colorectal surgery; paradoxically, it appears to result in significantly more surgical-site infections. (Funded by Innocoll Technologies; ClinicalTrials.gov number, NCT00600925.)

Purpose: This study was undertaken to determine the risks of cancer in unresectable polyps and to compare the short-term outcome of laparoscopic colectomy with that of open colectomy for benign polyps., Methods: A retrospective review of all patients (n = 165) undergoing colectomy for an adenoma unresectable at colonoscopy was performed on patients collected in a prospective database. One hundred four patients underwent laparoscopic colectomy and 61 underwent open colectomy between 1991 and 2003. Follow-up was 7 to 155 (median, 90) months., Results: In the laparoscopic group, 85% of the patients underwent a right colectomy and 15% underwent a left colectomy or a sigmoidectomy. Conversion to open colectomy occurred in 4.8% of the cases. Complications occurred in 14% of the patients, including 1 death. The median length of stay was 4 days. At final pathology, cancer was diagnosed in 15 patients: stage I in 8 patients, stage II in 5, and stage III in 2. In the open colectomy group, 69% of the patients underwent right colectomy. The complication rate reached 23% (P = .13), including death in 2 patients. The median length of stay was 6 days (P < .01). Cancer was diagnosed in 6 patients: stage I in 5 patients, and stage II in 1. Proximal (10 cm) and distal (13 cm) margins, lymph nodes harvest (9), incidence of cancer (13%), and high-grade dysplasia (22%) were similar between groups. There were no local recurrences, trocar site implants, or deaths due to cancer., Conclusion: Laparoscopic colectomy for polyps unresectable at colonoscopy is safe. Oncologic resection of the colon should be performed for all colonoscopically unresectable polyps due to the risk of cancer.

Background: Natural orifice transluminal endoscopic surgery (NOTES), a recent development in the field of minimally invasive surgery, provides theoretical advantages over open and laparoscopic surgery. Challenges with the use of NOTES for colon resections include the need to extract a large specimen and perform an intestinal anastomosis. A transanal single-port laparoscopic proctectomy uses the potential advantages of NOTES yet provides easy specimen extraction and anastomosis., Methods: Fresh frozen then thawed human cadavers were used. Access was obtained via transanal mucosectomy, and a transanal endoscopic microsurgery (TEM) system was used to perform the proctectomy once the procedure was above the pelvic floor. After the peritoneal cavity was entered, a hand port was placed through the sphincter and above the pelvic floor. The left colon was mobilized using two 5-mm working ports and a 10-mm camera port for the flexible-tipped laparoscope that were placed through the hand port. The specimen was removed transanally., Results: The critical steps for an oncologic resection of the rectum were achieved using a combination of TEM and laparoscopic instrumentation transanally. The rectum and mesorectum were mobilized. The left ureter was identified and preserved, the inferior mesenteric artery (IMA) ligated at its origin, the inferior mesenteric vein ligated near the ligament of Treitz, the proximal colon mobilized for transanal extraction, the specimen resected proximal to the ligated IMA, and a hand-sewn coloanal anastomosis performed. Postresection examination showed preservation of the hypogastric nerves and an intact mesorectum. Challenges included maneuverability around the sacral promontory and length of the instruments. However, this was easily overcome by the use of long reticulating instruments and a flexible-tipped laparoscope., Conclusions: Transanal single-port low anterior resection using TEM and laparoscopic techniques is feasible and can maintain the principles of an oncologic resection.

Purpose: This study was designed to compare short-term outcomes of laparoscopic vs. open total abdominal colectomy and end ileostomy for severe ulcerative colitis and to evaluate the impact of the initial surgical approach on subsequent operations for three-stage restorative proctocolectomy., Methods: Perioperative demographic and outcome data for patients with severe ulcerative colitis who underwent laparoscopic (n = 37) or open (n = 41) total abdominal colectomy at the initial stage of a three-stage restorative proctocolectomy were compared. Each stage was analyzed independently by using two-tailed t-tests and analysis of covariance., Results: Patients who underwent laparoscopic total abdominal colectomy had higher serum albumin (P = 0.0003), less inpatient narcotic usage (P = 0.0143), faster return of bowel function (P = 0.0001), and shorter length of stay (P = 0.039). There were no differences in perioperative parameters for the restorative proctectomy and ileostomy closure. The laparoscopic total abdominal colectomy patients underwent subsequent restorative proctectomy 49 days sooner (P = 0.0044) and ileostomy closure 17 days sooner (P = 0.00003) than the open total abdominal colectomy patients., Conclusions: Laparoscopic abdominal colectomy for severe ulcerative colitis in selected patients is safe and is associated with short-term benefits that may lead to faster recovery and progression to completion of restorative proctocolectomy.

Introduction: Beginning in 2003, the American Society of Colon and Rectal Surgeons has annually sponsored a laparoscopic colon and rectal surgery instructional course using a cadaver model. This study reports the adoption rate and postcourse practice patterns of participants., Methods: All prior participants of hands-on courses from 2003 to 2005 were asked to participate in a 25-question survey. Questions probed practice setting, prior laparoscopic experience, motivation for course participation, time to, indication for, and type of first laparoscopic colectomy, experience prior to cancer resection, factors facilitating skill acquisition, and impact on practice from course completion., Results: A total of 43 of 63 participants completed the survey and 53% had performed at least 1 laparoscopic colon resection prior to the course. A laparoscopic colon resection was performed within 1 week of the course by 52% of participants and within 1 month by 90%. Laparoscopic colectomy was performed frequently postcourse with 42% performing between 1 and 5 laparoscopic colectomies/month and 42% between 5 and 10. Hand-assisted technologies lowered the threshold for performance of first laparoscopic colectomy for 62% of participants. Cancer resection was the first procedure for 31% and 36% performed between 5 and 10 colectomies prior to cancer resection. Most important factor in particular course selection was a cadaver model (77%). A majority of the participants would require course completion prior to granting hospital privileges (73%) and would recommend the course to other surgeons (97%)., Conclusions: Cadaver course completion enables rapid integration of laparoscopic colon resection into clinical practice. Experience prior to laparoscopic resection of cancer is modest. Hand-assisted technologies promote technique acquisition.

Purpose: The long-term outcome of laparoscopic ileocolic resection in patients with Crohn's disease is not well defined. This study was designed to define the surgical recurrence rate after laparoscopic ileocolic resection for Crohn's disease and to compare it with that seen after open ileocolic resection., Methods: A retrospective review of 113 records of patients who underwent index ileocolic resection for terminal ileal Crohn's disease was performed (1987-2003). Recurrence was defined as development of new preanastomotic Crohn's disease requiring surgical intervention. Details of recurrence and use of chemoprophylaxis was determined by phone interview and chart review., Results: Sixty-three patients (26 males; mean age, 35.2 years) underwent laparoscopic ileocolic resection and 50 had open ileocolic resection (17 males; mean age, 37.1 years). Surgical recurrence developed in 6 of 63 patients (9.5 percent) in the laparoscopic ileocolic resection group (mean follow-up, 62.9 months) and in 12 of 50 patients (24 percent) in the open ileocolic resection group (mean follow-up, 81.8 months). Rates of chemoprophylaxis were similar between groups (laparoscopic ileocolic resection, 39 percent; open ileocolic resection, 54 percent; P = not significant). Median times to recurrence after laparoscopic ileocolic resection and open ileocolic resection were 60 (range, 36-72) months and 62 (range, 12-180) months, respectively. Fifty percent of the recurrences in the laparoscopic ileocolic resection group and 4 of 12 in the open ileocolic resection group were able to be retreated laparoscopically. Re-recurrence occurred in 4 of 12 open ileocolic resection patients (33 percent) at a mean of 63.6 months, and one patient had a third recurrence at 28 months., Conclusions: In this study, the long-term outcome after laparoscopic ileocolic resection was not shown to be statistically different from that of open ileocolic resection. The relatively low recurrence rates in both groups may be explained by our aggressive use of chemoprophylaxis.

Purpose: Endocavitary radiation is a treatment option for selected patients with rectal cancer, but concern exists for the effectiveness of salvage abdominoperineal resection. This study was designed to examine outcomes after salvage abdominoperineal resection for recurrence after endocavitary radiation., Methods: A prospective database was used to identify patients undergoing abdominoperineal resection after endocavitary radiation from 1985 to 2001. Office records and a tumor registry were used for disease status and survival data. Survival was calculated using the Kaplan-Meier method and groups compared using the Mantel-Haenszel test., Results: Thirty-eight patients underwent salvage abdominoperineal resection. The mean time to recurrence after completion of endocavitary radiation was 21 +/- 27 months, with 29 percent having persistent disease, 63 percent recurrent disease, and 8 percent a second primary. At abdominoperineal resection, 47 percent had tumor transection, specimen perforation, or injury to the genitourinary or gynecologic tract. Nine patients (24 percent) had positive radial margins. The mean time to perineal wound healing was 56 +/- 74.1 days postoperatively, with 36.8 percent taking more than 60 days. Seventeen patients (45 percent) re-recurred at a mean of 21 +/- 25 months after salvage, with a local control rate of 26 percent at 45 +/- 37 months of follow-up. Median disease-specific survival from completion of endocavitary radiation was 115.5 months, with a five-year, disease-specific survival rate of 66 percent. Patients with recurrent disease after endocavitary radiation had significantly (P = 0.025) better disease-specific survival than those with persistent disease (median survival 115 vs. 25 months)., Conclusions: Although technically difficult and associated with a high morbidity, abdominoperineal resection can salvage a significant fraction (55 percent) of patients failing endocavitary radiation. A high index of suspicion for recurrence and a tenacious approach to its diagnosis are essential for optimal outcomes.

Laparoscopic colon and rectal surgery has gained popularity over the last 10 years. The experience obtained from the more simple surgeries, such as cholecystectomy and appendectomy, and the development of better instruments have made colorectal standard laparoscopic surgery an easier procedure. However, the downside associated with this technique includes longer operative times, higher costs, loss of tactile sensation, and a two-dimensional view. In the last 5 years, a new type of instrument has appeared on the market: the hand-assist device. It gives back the tactile feeling and allows the surgeon to retrieve a three-dimensional evaluation of the abdomen. This instrument has changed the laparoscopic surgery field and permitted the expansion of laparoscopic colectomy to the most challenging and complex cases. Hand-assisted laparoscopic surgery seems to retain the same benefits as standard laparoscopic surgery and improve the operative time and the learning curve. This article reviews the benefits and the indications for the use of the hand-assist device, and the characteristics and types of hand-assist devices available and their instruction for use. It also focuses on the technical aspects of hand-assisted laparoscopic surgery.

Background: This study was conducted to determine if laparoscopic colon surgery has changed the incidence of wound complications after colon resection., Methods: Eighty-three patients were randomized to undergo either laparoscopic (LCR) or open colon resection (OCR) for cancer at our institution as part of a multicenter trial. Data were tabulated from review of the prospective database and physician records., Results: Thirty-seven patients were randomized to LCR and 46 to OCR. Seven patients in the LCR group were converted to OCR. LCR was performed using a limited midline incision for anastomosis and specimen extraction. Incision length was significantly greater (p <0.001) in the OCR group (19.4 +/- 5.6 cm) compared to the LCR extraction site (6.3 +/- 1.4 cm). Wound infections occurred in 13.5% of patients after LCR (2.7% trocar, 10.8% extraction sites) and in 10.9% of patients after OCR. Over a mean follow-up period of 30.1 +/- 17.8 months, incisional hernias developed in 24.3% of patients after LCR and 17.4% after OCR. In the LCR group, extraction sites accounted for 85.7% of all wound complications., Conclusions: The extraction site for LCR is associated with a high incidence of complications, comparable to open colectomy. Strategies to alter operative technique should be considered to reduce the incidence of these complications.

Purpose: The purpose of this study was to determine the effect of excising abdominal trocar wound sites after pneumoperitoneum on the rate of trocar site tumor implantation in a hamster model. This would help determine whether tumor cells seed trocar sites during or after pneumoperitoneum., Methods: A total of 0.5 ml of GW-39 human colon cancer cell suspension at 2.5 percent v/v (8 x 10(5) cells) was injected into the abdomens of 77 hamsters through a midline incision. Animals were subjected to ten minutes of pneumoperitoneum, after placement of four abdominal trocars, and then randomly assigned to undergo either simple suture closure or 4-mm radius trocar wound site excision at the end of the procedure. Gross and microscopic tumor implants were documented seven weeks later., Results: There were three and four deaths in simple suture closure and wound site excision groups, respectively. Of the remaining 35 hamsters in each group, tumor cells implanted at 89 and 78 percent of trocar sites, respectively (P < 0.03). There was no significant difference between the two groups in tumor implantation at midline laparotomy sites. Wound site excision also resulted in fewer palpable tumors (44 vs. 61 percent; P < 0.01) and a lower tumor implantation rate (49 vs. 74 percent; P < 0.05) at all four concurrent sites compared with simple suture closure., Conclusions: Excision of laparoscopic abdominal trocar wound sites can significantly, but not completely, reduce tumor implantation rate compared with simple wound closure.

Unlabelled: This study was undertaken to determine the early experience of the embers of the COST Study Group with colorectal cancer treated by laparoscopic approaches., Method: A retrospective review was performed of all patients with colorectal cancer treated with laparoscopy by the COST Study Group before August 1994. Tumor site, stage, differentiation, procedure completion, presence of recurrence (local, distant, trocar site), and cause of death were analyzed., Results: A total of 372 patients with adenocarcinoma of the colon and rectum were treated by laparoscopic approach between October 1991 and August 1994 (170 men and 192 women): right colectomy, 170; sigmoid colectomy, 55; low anterior resection, 56; abdominoperineal resection, 44; left colectomy, 22; colostomy, 8; total colectomy, 6; transverse colectomy, 7; exploration, 2. Conversion to an open procedure was required in 15.6 percent of cases. Operative mortality was 2 percent. Tumor characteristics were as follows: TNM state: I, 40 percent; II, 25 percent; III, 18 percent; IV, 17 percent; Differentiation: well-moderate, 88 percent; poor, 12 percent; carcinomatosis, 5 percent. Local (3.6 percent) and distant implantation occurred in four patients (1.1 percent). Only one of these patients died a cancer-related death (Stage III at 36 months). Cancer-related death rates increased with increasing stage of tumor: I, -4 percent; II, 17 percent; III, 31 percent; IV, 70 percent., Conclusion: A laparoscopic approach to colorectal cancer results in early outcome after treatment that is comparable with conventional therapy for colorectal cancer. A randomized trial is needed to compare long-term outcomes of open and laparoscopic approaches with colorectal cancer.

The safety of minimally invasive colectomy (laparoscopic or laparoscopically assisted colectomy) has not been evaluated in the elderly patient. Therefore, a prospective study of the outcome of minimally invasive colectomy (MIC) in patients aged 65 years or older was undertaken. Between October 1991 and September 1993, 103 elderly patients underwent attempted MIC (right colectomy, 53; left colectomy, sigmoid colectomy, or anterior resection, 36; abdominoperineal resection, 12; and total proctocolectomy with ileostomy, 2); 81 procedures were successfully completed. Complications occurred in 23% of patients converted to laparotomy (including one death) and in 25% undergoing successful MIC (two deaths, p = ns). The average length of postoperative stay was 5.3 days in the MIC group and 8.1 days for patients converted to laparotomy (p < 0.001). These results compare favorably with published results of traditional colectomy for elderly patients. We conclude that MIC is safe in the elderly patient and that further studies are warranted.

From 1980 to 1983, 20 patients had abdominal colectomy with primary ileorectal anastomosis. Fourteen operations were elective and six were emergency. Elective indications included familial polyposis (five), inflammatory bowel disease (four), colon cancer associated with multiple polyps (four), and colon cancer associated with diverticulosis and a history of massive hemorrhage (one). Emergency operations were performed for obstructing sigmoid or rectosigmoid cancer (three), massive lower gastrointestinal hemorrhage (two), and right colon cancer associated with obstructing diverticulitis (one). All patients survived the operation; in three patients complications developed in the immediate postoperative period for a morbidity of 15%. Our experience suggests that abdominal colectomy with primary ileorectal anastomosis can be safely performed in carefully selected cases.