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As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay.Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes.Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing.The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

Purpose Enhanced recovery pathways (ERPs) are associated with reduced complications and length of stay. The validation of the I-FEED scoring system, advances in perioperative anesthesia, multimodal analgesia, and telehealth remote monitoring have resulted in further evolution of ERPs setting the stage for same day discharge (SDD). Pioneers and early adopters have demonstrated the safety and feasibility of SDD programs. The aim of this study is to evaluate the impact of a pilot SDD ERP on patient self-reported pain scoring and narcotic usage. Methods A quality improvement pilot program was conducted to assess the impact of a SDD ERP on post-operative pain score reporting and opioid use in healthy patients undergoing elective colorectal surgery as an alternative to post-operative hospitalization during the COVID-19 pandemic (May 2020-December 2021). Patients were monitored remotely with daily telephone visits on POD 1-7 assessing the following variables: I-FEED score, pain score, pain management, bowel function, dietary advancement, any complications, and/or re-admissions. Results Thirty-seven patients met the highly selective eligibility criteria for “healthy patient, healthy anastomosis.” SDD occurred in 70%. The remaining 30% were discharged on POD 1. Mean total narcotic usage was 5.2 tablets of 5 mg oxycodone despite relatively high reported pain scores. Conclusions In our initial experience, SDD is associated with significantly lower patient narcotic utilization for postoperative pain management than hypothesized. This pilot SDD program resulted in a change in clinical practice with reduction of prescribed discharge oxycodone 5 mg quantity from #40 to #10 tablets.

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

As one of the 12 clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, the Colorectal Pathway intends to deliver didactic content organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure (laparoscopic right colectomy, laparoscopic left/sigmoid colectomy, and intracorporeal anastomosis during minimally invasive (MIS) ileocecal or right colon resection). In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic right colectomy which surgeons should be familiar with.Using a systematic literature search of Web of Science, the most cited articles on laparoscopic right colectomy were identified, reviewed, and ranked by the SAGES Colorectal Task Force and invited subject experts. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, with emphasis on relevance and impact in the field, findings, strengths and limitations, and conclusions.The top 10 seminal articles selected for the laparoscopic right colectomy anchoring procedure include articles on surgical techniques for benign and malignant disease, with anatomical and video illustrations, comparative outcomes of laparoscopic vs open colectomy, variations in technique with impact on clinical outcomes, and assessment of the learning curve.The top 10 seminal articles selected for laparoscopic right colectomy illustrate the diversity both in content and format of the educational curriculum of the SAGES Masters Program to support practicing surgeon progression to mastery within the Colorectal Pathway.

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.

Same-day discharge (SDD) after colectomy is feasible but requires effective post-discharge remote follow-up. Previous studies have used in-person home visits or a mobile health (mHealth) phone app, but the use of simple telephone calls for remote follow-up has not yet been studied. Therefore, the objective of this study was to compare outcomes after SDD for minimally invasive colectomy using mHealth or telephone remote post-discharge follow-up.A prospective cohort study was undertaken at two university-affiliated colorectal referral institutions from 02/2020 to 05/2021. Adult patients without significant comorbidities undergoing elective minimally invasive colectomy. Patients were discharged on the day of surgery based on set criteria. Post-discharge remote follow-up was performed using a mHealth app at site 1 and scheduled telephone calls at site 2 up to postoperative day (POD) 7. The main outcome for this study was the success rate of SDD, defined as discharge on POD0 without emergency department (ED) visit or readmission within the first 3 days.A total of 105 patients were recruited (site 1, n = 70; site 2, n = 35). Overall, 75% of patients were discharged on POD0 (site 1 81% vs. site 2 63%, p = 0.038), of which only two patients required an ED visit within the first 3 days, leading to an overall success rate of 73% (site 1 80% vs. site 2 60%, p = 0.029). The incidence of 30-day complications (16% vs. 20%, p = 0.583), ED visits (11% vs. 11%, p = 1.00), and readmissions (9% vs. 14%, p = 0.367) were similar between the two sites. There was only one patient at each study site that went to the ED without instructions through remote follow-up.A high proportion of patients planned for SDD were discharged on POD0 with few patients requiring an early unplanned ED visit. These results were similar with an mHealth app or telephone calls for post-discharge remote follow-ups, suggesting that SDD is feasible regardless of the method of post-discharge remote follow-up.

Transanal total mesorectal excision (taTME) is a surgical approach for low rectal cancer with a learning curve estimated at 40–50 cases. The experience among taTME surgeons beyond their learning curve is limited. A retrospective analysis of all taTME cases performed for rectal cancer at two tertiary care hospitals from 2014 to 2019 was conducted. Transanal surgeons had previously performed > 50 taTME cases. Demographic, perioperative, and short-term outcomes were analyzed. Among 54 taTME patients, 74.1% were male and 27.8% had a BMI ≥ 30. Tumors were stage I (8), II (13), III (29), and IV (4). Complex cases included 4 local recurrences, 4 prior liver resections, and 2 with prior prostate cancer. Thirty tumors were located ≤ 6 cm from the anal verge. On staging MRI, 12 had a positive predicted circumferential radial margin (+CRM), and 4 had internal anal sphincter involvement (+IAS). Forty-seven patients received neoadjuvant therapy. A 2-team approach was used in 51 patients with laparoscopic (83.3%) or robotic (16.7%) abdominal assistance with a 9.2% conversion rate. Low anterior resection with sphincter salvage was achieved in 87% with 8 patients requiring intersphincteric resection. Anastomoses were hand-sewn in 57.4% and all patients were diverted. Median LOS was 5 days with a 42.6% 30-day morbidity rate and 3 postoperative mortalities (ARDS, pulmonary embolism and pseudomembranous colitis). Complete and near complete TME grade was achieved in 94.4% with a 3.7% rate of +CRM. At a median follow-up of 28 months, local and distant recurrence rates were 3.9% and 17.6%, respectively, with no cancer-related mortality. Indications for taTME at experienced centers have expanded to include complex reoperative cases, local recurrences, metastatic cancer, and tumors with threatened CRM or IAS with evidence of post-treatment tumor regression. In the latter cases, taTME achieves good short-term outcomes and may facilitate R0 resection.

Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials.We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection.We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years.This was a multicenter trial.Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge.Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy.Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention.This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34).The predetermined sample size to adequately reduce the risk of type II error was not achieved.Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560.ANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero).

Background Trimodality therapy with neoadjuvant chemoradiation (nCRT), surgery, and adjuvant chemotherapy is the standard treatment for locally advanced rectal cancer. There is evidence that surgery can be deferred in patients with complete response (CR) to nCRT, a strategy termed “watch-and-wait” (WW). We compare WW to surgery in patients with CR to nCRT. Study Design We reviewed records of patients treated with nCRT for nonmetastatic rectal cancer at our institution. Complete endoscopic response (CER) was defined as negative digital rectal exam and negative endoscopy at the end of neoadjuvant therapy (NAT). Clinical complete response (cCR) was defined as CER with negative rectal MRI. Patients with CER refusing surgery were offered WW, which included strict surveillance with digital rectal exam and endoscopy. Results From January 2015 through February 2019, 465 patients completed nCRT; 406 patients had response assessment, of which 95 (23%) had CER. Of these patients, 53 patients underwent WW and 42 patients had surgery. Median follow-up was 35 months. In the WW group, 3-year freedom from local regrowth was 85%. In the surgical and WW groups, 3-year overall survival, rectal cancer-specific survival, and freedom from nonregrowth recurrence were 100% vs 88% (p = 0.03), 100% vs 95% (p = 0.16), and 92% vs 85% (p = 0.36), respectively. Of the 6 WW patients with local regrowth, 5 (83%) eventually developed distant recurrence. Conclusions WW in lieu of surgery appears to be a safe and feasible treatment approach for patients achieving CR to nCRT. Careful evaluation to confirm cCR after nCRT is valuable in selecting patients for WW.

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.

In the treatment of colorectal cancer, total mesorectal excision (TME) has risen as the gold standard in the surgical treatment of this disease in order to obtain negative distal and circumferential radial margins. Since introduction in 2010, transanal TME has aimed to decrease the rate of positive margins and improve the quality of the dissection while decreasing the complications associated with a transabdominal low pelvic dissection. We retrospectively reviewed 25 cases of transanal TME completed between December 2014 and August 2017. Most of the patients in our case series were male (60%) with an average age of 57.1 years, BMI of 28.4 kg/m2, and with an American Society of Anesthesiologists score of II. The average tumor was midrectal (about 5.9 cm from the anal verge), clinically T3-T4 (92%), and had undergone neoadjuvant therapy (96%). The average operation was about six hours and 44 minutes with ileostomy placed most of the time (92%). In all the cases where the TME quality was graded, the specimens were reported to have been complete (grade I). There were no positive distal, radial, or proximal margins. The average hospital stay was about 5.9 days. The rate of minor complications was about 48 per cent and major complications occurred about 16 per cent of the time.

Anastomotic leak rates in colorectal surgery remain persistently high despite increased awareness of contributing factors, low threshold for proximal fecal diversion, and modern technologies to better assess bowel perfusion. Leak rates for low colorectal anastomoses range 3–30% with risk factors including malnutrition, smoking, immunosuppression, prior radiation therapy, obesity, and male gender. Technical factors such as tension on the anastomosis and adequacy of the blood supply also play a critical role in the occurrence of leaks. This chapter will review intraoperative strategies to assess the integrity of colorectal anastomoses, reduce the risk of anastomotic leaks, and salvage a failed anastomosis and ischemic colonic conduit. Reconstructive techniques to salvage intraoperative and postoperative anastomotic leaks will also be reviewed.

In the treatment of colorectal cancer, total mesorectal excision (TME) has risen as the gold standard in the surgical treatment of this disease in order to obtain negative distal and circumferential radial margins. Since introduction in 2010, transanal TME has aimed to decrease the rate of positive margins and improve the quality of the dissection while decreasing the complications associated with a transabdominal low pelvic dissection. We retrospectively reviewed 25 cases of transanal TME completed between December 2014 and August 2017. Most of the patients in our case series were male (60%) with an average age of 57.1 years, BMI of 28.4 kg/m², and with an American Society of Anesthesiologists score of II. The average tumor was midrectal (about 5.9 cm from the anal verge), clinically T3-T4 (92%), and had undergone neoadjuvant therapy (96%). The average operation was about six hours and 44 minutes with ileostomy placed most of the time (92%). In all the cases where the TME quality was graded, the specimens were reported to have been complete (grade I). There were no positive distal, radial, or proximal margins. The average hospital stay was about 5.9 days. The rate of minor complications was about 48 per cent and major complications occurred about 16 per cent of the time.

Anorectal physiology and bowel continence is a complex and dynamic coordination of the reservoir functional capacity of the rectum, dynamic interplay with pelvic floor musculature, and timely contraction and relaxation of the sphincter muscle complex. Surgical alteration of the rectum in the form of partial or complete resection significantly impacts the patient’s bowel habits. Transanal surgical partial or total resection is associated with postoperative functional impairment in bowel incontinence. This chapter reviews the impact of TAMIS and taTME on bowel functional outcomes.

Stage II–III rectal cancer requires multidisciplinary cancer care, and adolescents and young adults (AYA, ages 15–39 years) often do not receive optimal cancer therapy. Overall, 3295 AYAs with clinical stage II–III rectal cancer were identified in the National Cancer Database. Factors associated with the receipt of adjuvant and surgical therapies, as well as overall survival (OS), were examined. The majority of patients were non-Hispanic White (72.0 %), male (57.5 %), and without comorbidities (93.8 %). A greater proportion of Black and Hispanic patients did not receive radiation (24.5 and 27.1 %, respectively, vs. 16.5 % for non-Hispanic White patients), surgery (22.4 % and 21.6 vs. 12.3 %), or chemotherapy (21.5 % and 24.1 vs. 14.7 %) compared with non-Hispanic White patients (all p

Transanal total mesorectal excision (taTME) is a “bottom-up” rather than “top-down” approach to radical proctectomy for rectal cancer. The surgical tools utilized to perform taTME continue to evolve. This chapter will review the robotic technical approach to performing taTME and summarize the published experience to date. Lastly, the perceived benefits and drawbacks associated with robotic taTME will be discussed.

There has been a significant evolution of the transanal excision technique over the past 3–4 decades. In 1983, Gerhard Buess introduced a disruptive technique in colorectal surgery, transanal endoscopic microsurgery (TEM). The initial results comparing TEM to the standard of care, transanal excision (TAE), revealed that TEM was associated with superior quality of resection demonstrated by the higher rate of achieving negative margins. Longer-term results revealed that TEM resection of rectal lesions also resulted in a lower local recurrence rate compared to TAE. TEM is one of the first colorectal surgical techniques with superior operative outcomes compared to the standard of care at the time (TAE). Over the last decade, multiple transanal platforms have been developed, and new techniques and terminology such as TAMIS (transanal minimally invasive surgery) have broadened the utility and applications of TEM. More broadly, the various terminologies used to describe the transanal endoluminal resection irrespective of the transanal access platform is TES (transanal endoscopic surgery). This chapter reviews the history and evolution of TES as well as comparing it to new endoluminal techniques such as EMR (endoscopic mucosal resection) and ESD (endoscopic submucosal dissection) for rectal lesions.

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

Robotic abdominal surgery is growing despite a paucity of clinical reports to evaluate its impact on patient outcomes. In this retrospective case series, we aim to analyze our early experience with robotic resection in 11 consecutive patients with chronic colonic diverticulitis complicated by fistula to bladder, vagina, or skin and to compare the results of the robotic approach to 20 patients undergoing laparoscopic resection for the same indication. Our main outcome measures include operative time, blood loss, conversion rate, transfusion rate, hospital length of stay, complications, readmission, and fistula healing rate. In our study, we found robotic resection for colonic diverticulitis with fistula was technically feasible and yielded 100 % fistula healing rate. The operative time, complication and readmission rates were similar to laparoscopy. A higher conversion rate, diverting stoma need, and longer hospital length of stay were noted in the robotic group; however, these findings could have been attributed to a higher number of cases involving rectal excision in the robotic group. Larger studies are needed to further examine the impact of robotic surgery on the outcome of patients with complicated chronic sigmoid diverticulitis.

Single-incision laparoscopic surgery (SILS) is gaining popularity for a wide variety of surgical operations and capitalizes on the benefits of traditional laparoscopic surgery without incurring multiple incision sites. Traditionally, SILS is performed by a midline periumbilical approach. However, such a minimally invasive approach may be utilized in patients who already have an abdominal incision. Our series retrospectively reviews 7 cases in which we utilized the fascial defect at the time of after ostomy reversal as our SILS incision site. In turn, we performed a variety of concurrent intra-abdominal procedures with excellent technical success and outcomes. Our study is the largest single-institution case series of this novel approach and suggests that utilizing an existing ostomy-site abdominal incision is a safe and effective location for SILS port placement and should be considered in patients undergoing concurrent procedures.

Hernias through the foramen of Winslow comprise 8 % of all internal hernias and the majority contain incarcerated bowel. Clinical signs are often non-specific and delay in diagnosis associated with a mortality rate that approaches 50 %. Management is urgent surgical reduction with bowel decompression and resection of devitalized bowel. A foramen of Winslow hernia (FWH) has traditionally been managed via an exploratory laparotomy incision and the vast majority of cases describe an open approach. We describe a minimally invasive approach to the management of an incarcerated FWH requiring decompression and bowel resection.

Background Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia. Methods This is an institutional review board approved, retrospective case series report. Results TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m2. Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1). Conclusion TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.

Healthcare costs in the United States are increasing. It is thought that as cost increases, outcomes should improve. The aim of this study was to analyze patient charges and mortality in the operative management of diverticulitis over time. A retrospective analysis of the Nationwide Inpatient Sample database was performed. Adults with diverticulitis who underwent laparoscopic or open partial colectomy were identified by ICD-9 codes. Multivariate analyses examined in-hospital mortality and total charges. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open vs. laparoscopic), and insurance status. From 1998 to 2010, 148,348 patients had a partial colectomy for diverticulitis. After adjusting for other covariates and inflation, the average charge of hospitalization per admission increased by $34,057 from 1998 to 2010. In the same observation period, adjusted in-hospital mortality decreased significantly by 2005 compared to 1998 (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.

Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.

Transanal endoscopic microsurgical (TEM) resection is associated with improved outcomes compared to transanal excision of rectal lesions. However, TEM equipment requires additional operative setup time, and tumor location dictates patient positioning. In 2010, Drs. Attallah, Albert, and Larach developed an alternative technique, transanal minimally invasive surgery (TAMIS). Herein, we describe our novel experience using endoscopic visualization to perform TAMIS (eTAMIS) to remove a large rectal polyp. This is a technical note describing a new surgical technique, eTAMIS. The technique is performed with the Gelpoint Path TAMIS platform (Applied Medical, Rancho Santa Margarita, CA) and a standard single-channel endoscope for visualization. Patient demographics, operative data, and pathologic data were recorded. eTAMIS was initially performed in a 50-year-old woman with an endoscopically defiant rectal mass discovered on routine screening colonoscopy. The lesion was a tubulovillous adenoma, 10 cm from the anal verge, anterior, and occupied 15–20 % of the circumference. The rectal mass was removed by eTAMIS. The operative time was 101 minutes, and the patient was discharged within 24 h without event. Final pathology revealed a focus of well-differentiated rectal adenocarcinoma with focal invasion into the muscularis mucosa (Haggit level 0, pTis) arising in the head of a pedunculated tubulovillous adenoma. At 1-year follow-up endoscopy, the patient had no evidence of recurrent mass or polyp. This is the first technical report describing endoscopic visualization for TAMIS. Endoscopic visualization facilitates intraluminal articulation and lens cleaning while minimizing extraluminal instrument collisions. eTAMIS is a practical and logical evolution of the visual approach to natural orifice transluminal endoscopic surgery and laparoendoscopic surgery.

Background There is a paucity of literature reporting minimally invasive proctectomy for ulcerative colitis (UC). We report a novel application of a robotic system to perform restorative proctectomy in patients with toxic UC. Methods Retrospective review, case series report. Results Robotic-assisted laparoscopic proctectomy with ileal J-pouch anal anastomosis was performed in three patients with toxic UC. All patients previously underwent urgent laparoscopic total abdominal colectomy. One female and two male patients were aged 39, 24 and 43, respectively. The procedures were performed safely with minimal complications. The robotic proctectomy operative time was reduced from 134 to 106 min. None of the patients have experienced fecal incontinence, nocturnal seepage or sexual dysfunction. Conclusions This is a case series report of a robotic-assisted laparoscopic proctectomy with restorative ileal J-pouch in patients with toxic UC. This technique has been previously described for use in patients with medically refractory UC and neoplasia associated with chronic UC. This series exemplifies an ideal application of a robotic system with improved visibility, rotation and ergonomics. Copyright © 2011 John Wiley & Sons, Ltd.

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.

Management of the parastomal hernia represents a common clinical dilemma for both the surgeon and patient. Once established, these defects are notoriously difficult to treat. Although most parastomal hernias can be managed nonoperatively, approximately 30% will require intervention secondary to complications such as obstruction, pain, bleeding, poorly fitting appliances, or leakage. Overall complication rates of up to 88%, combined with a growing body of literature citing decreased patient morbidity and improved outcomes with laparoscopic tension-free mesh repair of ventral hernias, have led many surgeons to apply these techniques to this difficult problem.This was a retrospective review of 21 consecutive patients who underwent laparoscopic repair of their parastomal hernias with ePTFE mesh.Nine (43%) were ileal conduits, seven (33%) were ileostomies, and five (24%) were colostomies. Eight patients had undergone prior hernia repair. Follow-up ranges from 1 to 36 months (average 14 months). There has been one recurrence (5%). Other complications included laparoscopic re-operation for obstruction of a urinary conduit (n=1), mesh removal for infection (n=2), Clostridium Difficile colitis (n=1), pneumonia (n=2), renal failure (n=1), surgical site infection (n=1), and bowel obstruction at a site remote from the hernia repair (n=2).The laparoscopic approach to parastomal hernias is a new technique that offers many potential advantages over conventional open repairs. Based on our initial experience, this repair seems to be associated with a low recurrence rate.

With increasing interest in natural orifice surgery, there has been a dramatic evolution of transanal and endoluminal surgical techniques. These techniques began with transanal endoluminal surgical removal of rectal masses and have progressed to transanal radical proctectomy for rectal cancer. The first transanal total mesorectal excision (taTME) was performed in 2009 by Sylla, Rattner, Delgado, and Lacy. The improved visibility and working space associated with the taTME technique is intriguing. This video manuscript outlines the training pathway followed by pioneers in the taTME technique, the process of implementation into clinical practice, and initial case report.A double board-certified colorectal surgeon with expertise in rectal cancer, minimally invasive total mesorectal excision, transanal endoscopic surgery (TES), and intersphincteric dissection, underwent taTME training in male cadaver models. Institutional review board (IRB) approval for a phase I clinical trial was achieved. The entire operative team including surgeons, nurses, and operative staff underwent taTME cadaver training the day prior to the first clinical case. The case was proctored by an expert in taTME.A 66-year-old male with uT3N1M0 rectal cancer located in the posterior distal rectum, underwent taTME with laparoscopic abdominal assistance, hand sewn coloanal anastomosis, and diverting loop ileostomy. The majority of the TME was performed transanally with laparoscopic assistance for exposure, splenic flexure mobilization, and high ligation of the vascular pedicles. Operative time was 359 min. There were no intraoperative complications. Pathology revealed a ypT2N1 moderately differentiated invasive adenocarcinoma, grade I TME, 1 cm circumferential radial margin, and 2/13 positive lymph nodes.Implementation of taTME into practice can be achieved by surgeons with expertise in minimally invasive TME, TES, pre-clinical taTME training in cadavers, case observation, proctoring, and ongoing mentorship. IRB peer review process and participation in a clinical registry are additional measures that should be employed.

The perioperative management of warfarin therapy increases the complexity of open inguinal herniorraphy.One thousand consecutive patients undergoing open inguinal herniorraphy were retrospectively reviewed. Patients on warfarin therapy were categorized into 3 groups: continued warfarin (CW), discontinued warfarin (DW), and discontinued warfarin with anticoagulation bridge (DWB).Eighty-eight patients were on chronic warfarin therapy. Warfarin was continued in 19 patients, discontinued in 54, and discontinued with bridge in 15 patients. Operative times were similar between the 3 groups. Length of stay was longest in the discontinued warfarin with bridge group (CW 0.74, DW 0.54, and DWB 3.33 days; P.0001). There was no significant difference in postoperative complications. The incidence of surgical site hematoma was higher in the continued warfarin and discontinued warfarin with bridge groups (CW 11%, DW 2%, and DWB 13%; P = .14).Continuation of warfarin may be a safe alternative to discontinuation of warfarin therapy in select patients undergoing open inguinal herniorraphy.

Objective To investigate the in vivo effect of short-term, moderate dosage synthetic dl-α-tocopherol acetate supplementation on platelet aggregation, coagulation profile, and simulated bleeding time in healthy individuals. α-tocopherol is the most biologically active isomer of Vitamin E, traditionally promoted as an antioxidant and therapeutic agent in cardiovascular disease. In vitro studies have suggested that α-tocopherol plays a role in the inhibition of platelet aggregation. However, further investigations into the effect of α-tocopherol on bleeding in vivo have not duplicated these findings. Materials and methods A total of 42 healthy volunteers complied with a 2-week abstinence period from the use of anti-platelet agents followed by determination of baseline platelet aggregation properties and coagulation studies using citrated whole blood. Moderate dosage Vitamin E (800 IU of dl-α-tocopherol acetate) was then self-administered for 14 days with reevaluation of platelet aggregation and coagulation profile, and simulated bleeding time after 14 days of Vitamin E supplementation. Results Forty subjects completed the 4-week study period. All 40 subjects demonstrated normal baseline coagulation studies and all had collagen-stimulated platelet aggregation assessment performed in triplicate. After Vitamin E supplementation, no significant difference was demonstrated in any study parameter. Conclusions Dietary supplementation with moderate dosage synthetic dl-α-tocopherol acetate did not significantly prolong bleeding or platelet aggregation in vivo . The affect of Vitamin E on platelet aggregation in vitro does not appear to be reproducible in vivo . Therefore, peri-operative discontinuation of Vitamin E may not be necessary.

Background General surgery residents are often not present for the critical intraoperative discussion between surgeon and pathologist regarding surgical pathology findings. Methods A prospective pilot study analyzed general surgery resident exposure to surgical pathology. Thereafter, an operating room was equipped to view frozen section images in real time and verbally communicate with the pathologist (TelePATHy). Total operative cases, cases using frozen sections, and use of TelePATHy were recorded. Results Most residents (78%) reported they were exposed to frozen-section surgical pathology ≤10% of the time. Overall, 202 operations were performed over the 123-day period. Forty-four cases had frozen-section specimens. General surgery residents were present for 40 cases. TelePATHy was successfully used in 32 cases (80%). Conclusions General surgery resident exposure to intraoperative pathology findings increased from a reported ≤10% to an observed 80%. TelePATHy is a novel intraoperative tool capable of maximizing the intraoperative experience of the surgical resident.

INTRODUCTION Activation of Vbeta8+ T cells with superantigen staphylococcal enterotoxin B (SEB) and use of an antitumor, anti-CD3 bispecific antibody (BsAb) leads to tumor protective immunity. We hypothesize that Vbeta8+ T-cell activation in combination with BsAb is crucial for tumor protective immunity in this model. METHODS Adolescent C3H/HeN mice were intravenously injected with syngeneic CL62 melanoma to establish pulmonary metastasis. Three days after establishing pulmonary metastasis, predominantly Vbeta8+ T cells are activated with 50 mug of intraperitoneal superantigen SEB. T cells were depleted at different time points in relation to SEB administration to assess the effect on protective immunity against a second tumor challenge. RESULTS Protective immunity is significantly (P < 0.008) decreased when Vbeta8+ depletion occurs 6 h after SEB injection, as growth of rechallenged CL62 melanoma occurred in 43%. Protective immunity is present at all other time points when mice survive Vbeta8+ T-cell depletion. Survival of animals treated with SEB/BsAb (82%) is significantly better (P < 0.002) than with SEB alone (60%) or nontreated control (0%). Survival when Vbeta8+ T-cell depletion occurred at 6 h and 48 h post-SEB is 72% and 77%, respectfully, and is statistically indistinguishable (P < 0.232 and P < 0.602). If T-cell depletion was conducted before SEB administration, however, the combination of SEB and BsAb did not result in significant protective immunity. T-cell depletion before the use of SEB alone, without BsAb, failed to result in significant protective immunity. CONCLUSIONS Depletion of Vbeta8+ T cells 6 h after activation disrupts the development of protective immunity.

Background Human saphenous vein (HSV) is the autologous conduit of choice for peripheral vascular reconstruction. Injury during harvest leads to vasospasm and a thrombogenic endoluminal surface. A proteomic transduction approach was developed to prevent vein graft vasospasm and thrombosis. Methods Recombinant HSP20 protein linked to the TAT protein transduction domain was generated in a bacterial expression system (TAT-HSP20). The effect of this protein on the inhibition of smooth muscle contraction was determined using rings of rabbit aorta and HSV in a muscle bath. In addition, the effects of TAT-HSP20 on platelet aggregation were determined in vitro using human citrated whole blood. Results Recombinant TAT-HSP20 inhibited norepinephrine-induced contraction of rabbit aortic and HSV segments. Similarly, TAT-HSP20 induced smooth muscle relaxation in HSV segments precontracted with norepinephrine. In human-citrated whole blood, platelet aggregation was significantly inhibited by TAT-HSP20 in a dose-dependent manner. Conclusions The results of this study demonstrate that recombinant TAT-HSP20 inhibits vascular smooth muscle contraction and platelet aggregation. This suggests that HSP20 may be an ideal effector molecule to target as a proteomic approach to enhance early vein graft patency rates by preventing acute vasospasm and thrombosis.

Purpose Sildenafil is an oral phosphodiesterase type 5 inhibitor that is a vasodilator used in the treatment of erectile dysfunction. Cyclic nucleotide-dependent vasorelaxation is associated with increases in the phosphorylation of the heat shock related protein 20 (HSP20). The purpose of this study was to determine if sildenafil-induced vasorelaxation is associated with increases in the phosphorylation of HSP20. Materials and methods Peptides containing an 11 amino acid enhanced protein transduction domain (PTD) and the functional 13 amino acid sequence of HSP20 with a phosphoserine (PTD-pHSP20) were synthesized using F-MOC technology. Rings of porcine coronary artery were suspended in a muscle bath and sub-maximally contracted with serotonin. Increasing concentrations of sodium nitroprusside (SNP; 0.01–10 μ m ), sildenafil (0.01–100 μ m ), or PTD-pHSP20 (0.1–1.0 m m ) were added to the baths and the percent relaxation was recorded. To determine if sildenafil-induced vasorelaxation was associated with increases in the phosphorylation of HSP20, rings of porcine coronary artery were untreated (control) or treated with SNP (10 μ m ) or sildenafil (100 μ m ) for 2, 5, and 10 min and then snap frozen. Extracted proteins were then separated using two-dimensional SDS-PAGE, transferred to a membrane, and probed for HSP20. Results Sildenafil induced vasorelaxation of pre-contracted coronary artery in a dose-dependent manner. Sildenafil-induced vasorelaxation was associated with an increase in the phosphorylation of HSP20. Transduction of peptide analogues of pHSP20 led to a dose-dependent relaxation of pre-contracted porcine coronary artery. Conclusions These findings suggest that sildenafil-induced vasorelaxation is associated with increases in the phosphorylation of HSP20 and that transduction of phosphopeptide analogues of HSP20 is sufficient for relaxation of vascular smooth muscle.

The introduction of robotic surgery has the potential to change colorectal surgery. Though the benefits of this instrument are still being evaluated, many hospitals have already started using it, so as not to be left behind in the competition for patients. While there are benefits in decreased conversion rates and possibly better long-term functional outcomes, there has yet to be published evidence that the use of a robot is cost effective in colorectal surgery. Given the high cost of investment, further work needs to be done in high-volume centers to identify a cost-effective strategy to implement this technology.

A collaborative effort among the 5 Universities of California (UC) Institutions was convened in November of 2011 to focus on opportunities for improvement in care of patients with benign and malignant colorectal diseases. Colorectal surgeons and other interested parties were present. Goals of the collaborative meeting included the following: to broaden our knowledge about geographically diverse patients at the different UC institutions, to integrate clinical research and care across the UC campuses to improve diagnosis and treatment of benign and malignant colorectal disease, to evaluate our current standard of care in colorectal surgery and develop interventions to improve quality of care, to develop multidisciplinary and multi-institutional conferences that would allow us to advance our knowledge of patients with unusual diseases, and to promote surgical education and training via exchange programs. The collaborative effort has strong leadership from all the UCs, an in-progress UC-wide data collection program, and resources from the successful implementation of a UC-wide breast health care system, all of which will help ensure a successful colorectal collaborative program.

Outcomes after surgery for diverticulitis are of continued interest to improve quality of care. The aim of this study was to assess variations in mortality, length of stay, and patient charges between geographic regions of the United States.A retrospective analysis of the Nationwide Inpatient Sample database was performed. Adults with diverticulitis who underwent laparoscopic or open segmental colectomy were identified using ICD-9 codes. Subset analyses were performed by state and then compared. Outcomes included mortality, length of stay (LOS), and total charges. Results were adjusted for age, race, gender, findings of peritonitis, stoma placement, Charlson comorbidity index, and insurance status on multivariate analysis.148,874 patients underwent segmental colectomy for diverticulitis from 1998 to 2010. Using California as the comparison state and after adjusting for covariates, in-hospital mortality was significantly higher in the State of New York (OR 1.32; 95 % CI 1.13-1.55; P 0.05) and Mississippi (OR 2.84; 95 % CI 1.24-6.51, P 0.02). Wisconsin had a significant lower mortality rate (OR 0.74; 95 % CI 0.59-0.94, P 0.01). LOS was 1.4 days longer in New York and 0.54 days shorter in Wisconsin than in California (P 0.01). Patients with age40 years, findings of peritonitis, and without private insurance had higher in-hospital mortality and longer length of stay. Average hospital charges differed dramatically between the states in the observation period. The highest hospital charges occurred in California, Nebraska, and Nevada while lowest occurred in Maryland, Wisconsin and Utah.Patients who undergo surgical treatment for diverticulitis in the United States have high geographic variation in mortality, LOS, and hospital charges despite adjusting for demographic and socioeconomic factors. Further analysis should be performed to identify the causes of outlier regions, with the goal of improving and standardizing best practices.

Approximately 20% of colorectal cancer patients present with established distant metastases.1 Metastases are often detectable with noninvasive imaging such as CT scan and MRI that are performed for staging of cancer. A diagnosis of stage IV disease then allows for appropriate operative and oncologic planning. Among these patients there is enormous heterogeneity with respect to sites of disease, extent of disease, symptoms, performance status, and comorbidities. The clinical spectrum at the time of diagnosis ranges from the asymptomatic patient with a single metastatic lesion to the rapidly deteriorating patient with colon obstruction and advanced, multiorgan metastases. While treatment algorithms may exist for some forms of metastatic disease such as a solitary liver lesion, others are still being defined.

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.

Background: Transanal endoscopic surgical (TES) resection using rigid transanal platforms (TEM, TEO) is associated with improved outcomes compared to traditional transanal excision (TAE) of rectal lesions. An alternative technique using a disposable single incision surgery platform was developed in 2009, transanal minimally invasive surgery (TAMIS), resulting in a surge in interest and access to transanal access platforms to perform TES. However, compared to rigid transanal access platforms, the disposable platforms do not facilitate internal rectal retraction and have limited proximal reach. A new long channel disposable transanal access platform has been developed (15 cm in length, 4cm in width) thereby facilitating endoluminal surgical access to the upper rectum and rectosigmoid colon.Methods: This is a retrospective case series report. Patient demographics and peri-operative outcome variables were recorded. The Gelpoint Path Long Channel was utilized in three patients with proximal rectal lesions that were not accessible using a standard disposable transanal access platform.Results: Three patients underwent TES excision of rectal adenomas using a long channel, disposable, transanal access platform. All patients were female, aged 51-53, BMI 23-32kg/m^2. The tumor size ranged from 2.4-8.5cm, 15-100% circumference, and proximal location from the dentate line ranged from 9-11cm. Final pathology revealed adenoma with negative margins in all three cases. The hospital length of stay ranged from 1-3 days and there were no perioperative complications. None of the patients have developed a local recurrence during the follow up period ranging from 5-11 months.Conclusions: The new long channel, disposable, transanal access platform facilitates transanal endoluminal surgical removal of lesions in the mid to upper rectum that may be difficult to reach using the standard disposable transanal access devices. We have successfully achieved 100% margin negative rate using this new device in this small series of patients with proximal rectal adenomas.

714 Background: Stage II-III rectal cancer (CA) requires a multidisciplinary approach to optimize outcomes. This study explores whether treatment disparities account for racial differences in outcomes of AYA (ages 15-39) patients. Methods: AYAs with clinical stage II-III rectal CA were identified in the National Cancer Database. Demographic, clinical, and pathologic features predictive of receipt of adjuvant and surgical therapies were examined as well as factors associated with overall survival (OS). Results: Most of the 3,295 patients were white (72.0%), male (57.5%) and free of comorbidities (93.8%). Income, education levels, and rates of health insurance coverage were higher for whites than for blacks or Hispanics. Clinical stage was balanced by race, but more blacks and Hispanics did not receive radiation (24.5% and 27.1%, respectively, vs 16.5% for whites), surgery (22.4% and 15.3%, vs 12.3%), or chemotherapy (21.5% and 24.1%, vs 16.7%; p < 0.05). Additionally, the average number of days before treatment was 34.0 for blacks and 33.3 for Hispanics, versus 27.5 for whites (p < 0.05). Multivariate analysis showed that receipt of neoadjuvant chemoradiation was less likely when patients were black (OR 0.7, 95%CI 0.5-0.9, p = 0.014), Hispanic (OR 0.6, 95%CI 0.4-0.9, p = 0.012), female (OR 0.8, 95% CI 0.63-0.94, p = 0.011), without insurance (OR 0.5, 95%CI 0.36-0.69, p < 0.001), or treated at a community cancer center (OR 0.5, 95%CI 0.36- 0.74, p < 0.05). Race significantly influenced treatment, regardless of disease stage. Although 5-year OS was lower (p < 0.05) in blacks (59.8±3.3%) and Hispanics (65.9±3.5%) compared to whites (74.9±1.1%), race did not impact mortality on Cox regression. Instead, mortality was associated with male sex (HR 1.5, 95%CI 1.1-2.0, p = 0.009), nodal positivity (HR 2.6, 95%CI 1.9-3.6, p < 0.001), nonsurgical therapy (HR 7.1, 95%CI 2.8-18.2, p < 0.001), no chemotherapy (HR 1.9, 95%CI 1.03-3.6, p = 0.04), poorly differentiated histology (HR 3.0, 95%CI 1.3-6.5, p = 0.007), and no insurance (HR 1.7, 95%CI 1.1-2.7, p = 0.022). Conclusions: Race-based socioeconomic and treatment disparities may contribute to survival differences among AYAs with rectal cancer.