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The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

PURPOSE Hereditary cancer syndromes infer high cancer risks and require intensive surveillance. Identification of high-risk individuals among patients with colorectal cancer (CRC) needs improvement. METHODS Three thousand three hundred ten unselected adults who underwent surgical resection for primary invasive CRC were prospectively accrued from 51 hospitals across Ohio between January 1, 2013, and December 31, 2016. Universal Tumor screening (UTS) for mismatch repair (MMR) deficiency was performed for all, and pathogenic germline variants (PGVs) were identified using multigene panel testing (MGPT) in those who met at least one inclusion criterion: MMR deficiency, diagnosed < 50 years, multiple primary tumors (CRC or endometrial cancer), or with a first-degree relative with CRC or endometrial cancer. RESULTS Five hundred twenty-five patients (15.9%) had MMR deficiency. Two hundred thirty-four of 3,310 (7.1%; 16% of the 1,462 who received MGPT) had 248 PGVs in cancer susceptibility genes. One hundred forty-two (4.3%) had a PGV in an MMR gene, and 101 (3.1%) had a PGV in a non-MMR gene. Ten with Lynch syndrome (LS) also had a non-MMR PGV and were included in both groups. Two (0.06%) had constitutional MLH1 hypermethylation. Of unexplained MMR-deficient patients, 88.4% (76 of 86) had double somatic MMR mutations. Testing for only MMR genes in MMR-deficient patients would have missed 18 non-MMR gene PGVs (7.3% of total PGVs identified). Had UTS been the only method used to screen for hereditary cancer syndromes, 38.6% (91 of 236) would have been missed, including 6.3% (9 of 144) of those with LS. These results have treatment implications as 5.3% (175 of 3,310) had PGVs in genes with therapeutic targets. CONCLUSION UTS alone is insufficient for identifying a large proportion of CRC patients with hereditary syndromes, including some with LS. At a minimum, 7.1% of individuals with CRC have a PGV and pan-cancer MGPT should be considered for all patients with CRC.

Pelvic floor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic floor imaging include fluoroscopic defecography, magnetic resonance defecography, and pelvic floor ultrasound. This collaboration opinion paper was developed by representatives from multiple specialties involved in care of patients with pelvic floor dysfunction (radiologists, urogynecologists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The final draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA).

Over 67,000 individuals died in the United States due to drug overdose in 2018; the majority of these deaths were secondary to opioid ingestion. Our aim was to determine surgeon perceptions on opioid abuse, the adequacy of perioperative and graduate medical education, and the role surgeons may play. We also aimed to investigate any differences in attending and resident surgeon attitudes.Anonymous online survey assessing surgeons' opioid counseling practices, prescribing patterns, and perceptions on opioid abuse, adequacy of education about opioid abuse, and the role physicians play.Two Accreditation Council for Graduate Medical Education accredited general surgery programs at a university-based tertiary hospital and a community hospital in the Midwest.Attending and resident physicians within the Departments of Surgery participated anonymously.Attending surgeons were more likely than residents to discuss posoperative opioids with patients (62% vs. 33%; p0.05), discuss the potential of opioid abuse (31% vs. 6%; p0.05), and check state-specific prescription monitoring programs (15% vs. 0%; p0.05). Surgeons and trainees feel that surgeons have contributed to the opioid epidemic (76% attending vs. 88% resident). Overall, attending and resident surgeons disagree that there is adequate formal education (66% vs. 66%) but adequate informal education (48% vs. 61%) on opioid prescribing. However, when attending physicians were broken down into those who have practiced ≤5 years vs. those with5 years experience, those with ≤5 years experience were more confident in recognizing opioid abuse (61% vs. 34%) and fewer young faculty disagreed that there is adequate formalized education on opioid prescribing (45% vs. 84%).Patient education should be improved upon in the preoperative setting and should be treated as an important component of preoperative discussions. Formalized opioid education should also be undertaken in graduate surgical education to help guide appropriate opioid use by resident and attending physicians.

Fecal incontinence is a prevalent health problem that affects over 20% of healthy women. Many surgical treatment options exist for fecal incontinence after attempts at non-operative management. In this article, the authors discuss surgical treatment options for fecal incontinence other than sacral neuromodulation.

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.

Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC.A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes ( 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively.Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients.Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.

Background For cirrhotic patients awaiting liver transplantation, the Model for End-Stage Liver Disease Sodium (MELD-Na) model is extensively studied. Because of the simplicity of the scoring system, there has been interest in applying MELD-Na to predict patient outcomes in the noncirrhotic surgical patient, and MELD-Na has been shown to predict postoperative morbidity and mortality after elective colectomy. Our aim was to identify the utility of MELD-Na to predict anastomotic leak in elective colorectal cases. Methods The American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database was queried (2012-2014) for all elective colorectal procedures in patients without ascites. Leak rates were compared by MELD-Na score using chi-square tests and multivariate logistic regression analysis. Results We identified 44,540 elective colorectal cases (mean age, 60.5 y ± 14.4, mean body mass index 28.8 ± 6.6 kg/m2, 52% female), of which 70% were colon resections and 30% involved partial rectal resections (low anterior resections). Laparoscopic approach accounted for 64.72% while 35.3% were open. The overall complication and mortality rates were 21% and 0.7%, respectively, with a total anastomotic leak rate of 3.4%. Overall, 98% had a preoperative MELD-Na score between 10 and 20. Incremental increases in MELD-Na score (10-14, 15-19, and ≥20) were associated with an increased leak rate, specifically in partial rectal resections (3.9% versus 5.1% versus 10.7% P Conclusions MELD-Na is an independent predictor of anastomotic leak in partial rectal resections. Anastomotic leak risk increases with increasing MELD-Na in elective colorectal resections, as does 30-d mortality and overall complication rate. As MELD-Na score increases to more than 20, restorative partial rectal resection has a 10% rate of anastomotic leak.

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 An increasing number of patients achieve a pathologic complete response (pCR) after neoadjuvant chemoradiation for locally advanced rectal cancer. Consensus guidelines continue to recommend oncologic resection followed by adjuvant chemotherapy in these patients. We hypothesize that there is significant variability in compliance with this recommendation. Methods The National Cancer Database was queried from 2006 to 2015 for patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation followed by oncologic resection with a pCR (ypT0N0). Hierarchical logistic regression models were used to generate risk and reliability-adjusted rates of adjuvant chemotherapy utilization in patients with pCR at each hospital. Results In total, 2421 pCR patients were identified. Five-year overall survival was improved in pCR patients who received adjuvant chemotherapy compared with those who did not (92 vs. 85%, p

Pilonidal disease represents a spectrum of disorders with abscesses and/or fistulous tracts arising from pits in the gluteal cleft. Clinical presentation varies between asymptomatic to severely lifestyle limiting disease. Hair removal and hygiene are important steps in the management of these patients. Abscess may be treated with incision and drainage, without antibiotics. Patients with more complex disease may need wide excision followed by either primary closure or healing by secondary intention. For patients with deep gluteal clefts or those with recurrent disease, one of multiple flap-based closures may be indicated.

The 2010 Patient Protection and Affordable Care Act (PPACA) 1 sought to reform healthcare in the United States through a myriad of initiatives that included expanding health insurance accessibility, mandating coverage, revising and expanding a multitude of government programs, and incentivizing improved quality and value in healthcare delivery. 2 One initiative aimed at containing costs and improving patient outcomes is the Hospital-Acquired Condition Reduction Program (HACRP). Like the Hospital Readmission Reduction Program (HRRP), the goal of this program is to stratify hospitals based on their outcomes, in this case a composite score of multiple hospital-acquired conditions (HACs), and financially penalize the bottom performers. It is important for surgeons and hospitals understand the metrics behind these measures, and to lend a voice to the discussion of the benefits and alternative strategies to quality improvement.

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. This Clinical Practice Guidelines Committee is charged with leading internationa

Fecal incontinence (FI) is defined as the involuntary passage of stool or flatus. It is a socially and physically debilitating condition affecting up to 15% of the adult population. Etiology of the disease is multifactorial, and consequently, disease management warrants a multimodal approach. Initial therapy consists of conservative measures, but when these fail, consideration should be given to surgical management. Sacral neuromodulation (SNM) is an emerging therapy due to its high reported success, long-term efficacy, low morbidity, and no reported mortality. Here we describe the technique of sacral nerve stimulator insertion.

The aim of this study was to evaluate whether survival differences are attributable to disproportionate access to stage-specific rectal cancer treatment recommended by the National Comprehensive Care Network.A retrospective analysis of the National Cancer Data Base between 1998 and 2006 was performed. A series of Kaplan-Meier survival analyses were used to compare 5-y survival among race cohorts. Propensity score matching was used to compare Caucasian and African American patients who received the same treatment by accounting for covariates.5-y overall survival in African Americans was 50.7% versus 56.2% in Caucasians (P 0.001). In patients with stage I-III disease, 5-y survival was 58.7% in African Americans versus 63.1% in Caucasians (P 0.001). Analysis of patients receiving surgery for stage I-III disease, revealed a 61.1% 5-y survival in African Americans versus 65.8% in Caucasians (P 0.001). Propensity score matching did not eliminate the racial disparity. The median survival for Caucasian patients was 109.6 mo as compared to 85.8 mo for African Americans (P 0.001).These data show that access to standard care appears to decrease but not eliminate the survival differences between African Americans and Caucasians with rectal cancer.

In an effort to optimize further the surgical management of colon cancer, many groups have advocated extended lymphadenectomy as a strategy to improve completeness of resection and lymph node harvest. This review evaluates lymphadenectomy according to the definitions for extent of lymph node dissection based on the guidelines provided by the Japanese Society of Cancer of the Colon and Rectum and the contemporary concepts of complete mesocolic excision and central vascular ligation. The proposed benefits of a D3 or central nodal dissection along root vessels in colon cancer is improving accuracy of lymph node evaluation and ensuring complete removal of lymph nodes that may harbor undetected tumor cells or other undefined immunologic processes important for metastases. Metastasis to central lymph nodes occurs in 1 to 8% of patients with colon cancer and is most commonly seen in T3 and T4 tumors. Although central lymph node metastasis is associated with decreased survival after resection, resection of the nodes, when present, may confer a survival benefit analogous to resection of metastasis at distant sites. Current data support a standardized anatomic approach to colonic resection with complete resection of the mesocolic envelope and ligation at least to the D2 level.

Background Following oncologic resection, adjuvant chemotherapy is associated with decreased recurrence and improved survival in stage 3 colon cancer. However, there is controversy regarding its use in stage 2 colon cancer with high-risk features (tumor depth T4, poorly differentiated, positive margin, and/or inadequate lymph node retrieval). Consensus guidelines recommend no adjuvant chemotherapy in the absence of these high-risk features (low-risk stage 2). Objective This study aimed to examine hospital characteristics associated with poor risk-adjusted, stage-specific guideline compliance for the use of adjuvant chemotherapy in stage 3 and low-risk stage 2 colon cancer. Design This was a retrospective study. Stepwise logistic regression was used to identify patient and hospital factors associated with administration of adjuvant chemotherapy. Hierarchical regression models were used to calculate risk- and reliability-adjusted rates of chemotherapy use and observed-to-expected ratios in each hospital's stage 2 low-risk and stage 3 patients. Settings Data were retrieved from the National Cancer Database. Patients Patients selected were adults treated with oncologic resection for stage 2 to 3 colon cancer between 2004 and 2010. Main outcome measures The primary outcome measured was receipt of adjuvant chemotherapy. Results A total of 167,345 patients were identified at 1395 hospitals. The mean overall risk-adjusted adjuvant chemotherapy rate was 65.3% for stage 3 and 15.2% for low-risk stage 2. Analysis of low outlier hospitals for stage 3 colon cancer, where adjuvant chemotherapy was underutilized, demonstrated that 62.8% were low-volume centers and 51.4% were community centers. Of high outlier hospitals for stage 2 low-risk disease, where adjuvant chemotherapy was overutilized, 87.2% were low-volume hospitals and 67.2% were community centers. Limitations Selection bias and the inability to compare specific chemotherapy regimens were limitations of this study. Conclusions Following oncologic resection, administration of adjuvant chemotherapy for low-risk stage 2 and stage 3 disease varies substantially among hospitals in the United States. Outlier hospitals were most likely to be low-volume community centers.

The transition from years of surgical training to independent surgical practice is a time to enjoy the well-earned achievement of completion of training. The early years of clinical practice bring about many challenges to the young surgeon. These include transitioning to a more independent role in the operating room, running an office and understanding the business aspects of medicine, building clinical networks to sustain a clinical practice, and building a professional and academic reputation. This article will discuss aspects that are unique to the early career surgeon. Where possible, I will use the available literature to augment the discussion, whereas, in other areas, I will offer my thoughts from personal experience on the topic.

Since the initial description by Heald of total mesorectal excision (TME), there has been a steady interest in the relationship between the quality of a rectal cancer resection and oncologic outcomes. The current point of controversy is the role for complete mesocolic excision (CME) in colon cancer surgery. To be able to understand the literature on this topic, we must first understand the meaning of the various definitions which have been proposed. We will then examine the impact of these techniques on survival after colon cancer surgery and the evolving role of minimally invasive surgery in these techniques.

The impact of recent preoperative opioid exposure on outcomes of colorectal surgery is unclear. Our aim was to evaluate the impact of preoperative opioid use on outcomes and opioid prescribing patterns after colorectal surgery.We performed a retrospective review of all patients undergoing elective resection at a single institution from 2015 to 2017. Primary outcomes included in-hospital narcotic use and cost. Secondary outcomes included postoperative surgical outcomes and discharge prescribing patterns.A total of 390 patients underwent elective colorectal surgery, of whom 63 (16%) had a recent history of preoperative opioid use. Opioid users had similar age, sex, American Society of Anesthesiologists score, and operative indication compared with opioid-naïve patients (P.05 for each). Postoperatively, the 30-day readmission rate was greater among opioid users (18% vs 9%, P = .03). Opioid users had greater total narcotic use (218 morphine milligram equivalents vs 111 morphine milligram equivalents, P = .04) and direct costs ($11,165 vs $8,911, P.01). These patients were also more likely to require an opioid prescription on discharge (90% vs 68%, P.01) and an opioid refill within 30 days (54% vs 21%, P.01).Recent preoperative opioid exposure among colorectal surgery patients was associated with increased opioid consumption and costs. Moreover, unadjusted analysis was pertinent for more readmissions after surgery among preoperative opioid users. This work underscores the negative impact of preoperative, chronic opioid use on surgical outcomes and highlights the need for developing protocols to minimize perioperative narcotics.

The Surveillance, Epidemiology, and End Results (SEER) program is a clinical database, funded by the National Cancer Institute (NCI), which was created to collect cancer incidence, prevalence, and survival data from U.S. cancer registries. By capturing approximately 30% of the U.S. population, it serves as a powerful resource for researchers focused on understanding the natural history of colorectal cancer and improvement in patient care. The linked SEER-Medicare database is a robust database allowing investigators to perform studies focusing on health disparities, quality of care, and cost of treatment in oncologic disease. Since its infancy in the early 1970s, the database has been utilized for thousands of studies resulting in novel publications that have shaped our management of colorectal cancer among other malignancies.

In the United States, colorectal cancer (CRC) is the third most common cancer in men and the second commonest cancer in women (746,000 vs. 614,000 cases, respectively in 2012) [1]. There is substantial variability in its worldwide incidence, with the highest incidence seen in developed regions and the lowest incidence recorded in developing regions (Fig. 1.1). The highest incidence is reported in Australasia (44.8 cases per 100,000 males), whereas males in Western Africa have the lowest incidence (4.5 per 100,000) and where geographic variability is reflective of inherent lifestyle differences. In 1969, Denis Burkitt made the observation that populations in low risk areas had an overall higher dietary fiber intake with a greater stool bulk and a more rapid colonic transit time when compared with Westernized countries [2]. Although controversial, the suggestion was that fiber depletion (as well as exposure to more refined carbohydrates) promoted carcinogenesis, however, there have been other later epidemiological studies which have failed to support Burkitt’s original hypothesis [3]. Despite this, the concept is supported by data showing that patients who migrate from areas of low to high incidence tend to develop the same incidence of CRC as their new adopted environment, [4] implying a potential role for dietary primary CRC prevention.

Rectal prolapse is a pelvic floor disorder, which causes severe compromise in quality of life. Although many variations have been described in surgical management, the most common approach is an abdominal rectopexy for most patients and a perineal approach in patients who are too frail to permit an abdominal approach. The abdominal operations are generally preferred with some minimally invasive method. Rectal intussusception is a rare condition, often diagnosed during defecography, which is generally medically managed.

During the past several decades, anal physiology testing has afforded us a more complete understanding of the complex interactions between pelvic anatomy and physiology. Techniques have been improved and validated in both normal volunteers and in states of disease. This chapter will give a detailed overview of the differing methods of anal physiology testing and provide clinical correlations as to when these tests may be useful, or conversely, in which situations clinical judgment should supersede testing.

Pelvic floor disorders are being diagnosed in women with increasing frequency. Disorders of the different compartments of the pelvic floor (anterior, middle, and posterior) often occur simultaneously. A multidisciplinary approach is often needed to pursue the proper workup and reach the optimal treatment regimen. Pelvic floor centers are emerging as a model in which to treat these complex patients. Lastly, we will highlight case examples of how a pelvic floor center can be beneficial to the workup and management of these patients.