Perineal Resection Research Articles

Weekend Effect in Emergency Colon and Rectal Cancer Surgery: A Prospective Study Using Data From the Dutch ColoRectal Audit.

Background: It is unclear whether emergency weekend colon and rectal cancer surgery are associated with worse outcomes (ie, weekend effect) because previous studies mostly used administrative data, which may insufficiently adjust for case-mix. Materials and Methods: Prospectively collected data from the 2012-2015 Dutch ColoRectal Audit (n=5,224) was used to examine differences in 30-day mortality and severe complication and failure-to-rescue rates for emergency weekend (Saturday and Sunday) versus Monday surgery, stratified for colon and rectal cancer. Analyses were adjusted for age, sex, body mass index, Charlson comorbidity index, American Society of Anesthesiologists classification score, tumor stage, presence of metastasis, preoperative complication, additional resection for metastasis or locally advanced tumor, location primary colon tumor, type of rectal surgery (lower anterior resection or abdominal perineal resection), and type of neoadjuvant therapy (short-course radiotherapy or chemoradiotherapy). Results: A total of 5,052 patients undergoing colon cancer surgery and 172 undergoing rectal cancer surgery were included. Patients undergoing colon or rectal cancer surgery during weekends had significantly more preoperative tumor complications compared with those undergoing surgery on a weekday. Additionally, differences in year of surgery and location of primary tumor were found for colon cancer surgery. Emergency colon cancer surgery during the weekend was associated with increased 30-day mortality (odds ratio [OR], 1.66; 95% CI, 1.10-2.50) and severe complications (OR, 1.29; 95% CI, 1.03-1.63) compared with surgery on Monday. Estimates for emergency weekend rectal cancer surgery were similar but not statistically significant, likely explained by small numbers. Conclusions: Weekend emergency colon cancer surgery was associated with higher mortality and severe complication rates. More research is needed to understand which factors explain and contribute to these differences.

The Estimate of the Impact of Coccyx Resection in Surgical Field Exposure During Abdominal Perineal Resection Using Preoperative High-Resolution Magnetic Resonance.

To estimate the improvement in surgical exposure by removal of the coccyx, during abdomino-perineal resection (APR), in rectal cancer patients. Retrospective study of 29 consecutive patients with rectal cancer was carried out. Using MR T2 sagittal series, the solid angle was estimated using the angle determined by the anterior resection margin and the tip of coccyx (no coccyx resection) or the tip of last sacral vertebra (coccyx resection). The solid angle provides an estimate of the tridimensional surface area provided by an original angle resulting in the best estimate of the surgeon's view/exposure to the critical dissecting point of choice (anterior rectal wall). The difference ("Gain") in surgical field exposure by removal of the coccyx was compared by the solid angle variation between the two estimates (with and without the coccyx). Routine removal of the coccyx determines an average 42% (95% CI 27-57%) gain in surgical field exposure area facing the anterior rectal wall at the level of the prostate/vagina by the surgeon. Fifteen (51%) patients had ≥30% (median) estimated gain in surgical field exposure by coccygectomy. There was no association between BMI, age or gender and estimated gain in surgical field exposure area. Routine removal of the coccyx during APR may result in an average increase in 42% in surgical field exposure during APR's perineal dissection. Precise estimation of surgical field exposure gain by removal of the coccyx may be predicted by MR sagittal series for each individual patient.

Grading quality of total mesorectal excision specimen by surgeons

Background: Total mesorectal excision has been gold standard since 1978. But standardization of surgery with quality assurance of total mesorectal excision specimen has been a challenging issue in developing countries. However, quality of macroscopic total mesorectal excision can be graded immediately by operating surgeon before specimen has been fixed in formalin and photographic documentation of gross specimen by surgeons is possible and practical.Objective: To grade macroscopic total mesorectal excision specimen by surgeon and document it photographically and compare it with reporting received from pathologist. Methods: A prospective observational study conducted from Jan 2014 to Jan 2016 at Department of Surgery, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal. All consecutive patients with rectal cancer (upper/middle and lower) without distant metastasis were included. Immediate after surgery, macroscopic specimen of TME were graded by operating surgeon and photo-documentation with one anterior, one posterior and two right and left lateral views of total mesorectal excision photos were taken and documented with printed form along with operative notes.Results: There were 40 patients with rectal cancer who underwent surgery during this period. Among those patients, the median age was 25 years of which 30% were females. Twenty-four patients underwent low anterior resection whereas thirteen had ultralow anterior resection and three had abdominal perineal resection. All patients had photo documentation. Complete mesorectal excision was seen in 36 patients and four patients had near complete total mesorectal excision when graded by surgeons. However, pathologist reported six (16.6%) patients having near complete mesorectum among those which had been graded as complete by surgeons.Conclusion: Grading of macroscopic total mesorectal excision specimen by surgeon is feasible and with use of photographic documentation, it can help to assess the quality of surgeons work and can be a good tool for feedback for surgeons to improve.

(P15) Rectal Cancer in Patients Less Than 50 Years Old: Presenting Symptoms, Staging and Treatment Decisions in a Single Institution

There is a well-documented increase in rectal cancers among younger patients with little understanding of their clinical presentation, baseline characteristics and treatment strategies. The aim of this study is to characterize the population of young patients (age less than 50) diagnosed with rectal cancer in our institution. This is a retrospective, single institution study. We identified 27 patients under the age of 50 diagnosed with rectal cancer between 2013 and 2017. Medical records were reviewed for patient characteristics, molecular studies and treatment plans. The median age at diagnosis was 41 years (range 28-48). There were 12 women. 5 patients (19%) had rectosigmoid disease. Patients were diagnosed with stage I (n = 3), Stage II (n = 8), stage III (n = 13) or stage IV (n = 3) disease. All stage IV patients were diagnosed with liver metastases at presentation and were treated with curative intent. All patients were diagnosed with adenocarcinoma; 3 (11%) had mucinous adenocarcinoma and 1 (4%) with mixed adeno-neuroendocrine carcinoma of the rectum (MANEC). The median follow up from date of diagnosis was 21 months (range 2-49). Two patients (7%) had a diagnosis of Crohn’s or Ulcerative Colitis. Five patients (19%) reported a family history of colorectal cancer and 1 (4%) reported a family history of Crohn’s disease. Ten patients (37%) reported a positive smoking history. The three most common presenting symptoms included rectal bleeding (n = 19, 70%), change in bowel habits/stool caliber (n = 12, 44%) and weight loss (n = 6, 22%). The median time between initiation of symptoms and tissue diagnosis was 3 months (range 0-12 months). All 27 patients were micro satellite stable. Molecular studies were documented for 12 patients (44%). Of those, 5 were noted to have clinically significant DNA variants, most commonly KRAS (n=4). 21 patients (78%) were treated with neoadjuvant chemoradiation therapy with Xeloda prior to definitive surgery. Those who were not were either unable to tolerate concurrent Xeloda (n = 1), received neoadjuvant chemotherapy alone (n = 2) or did not receive neoadjuvant therapy prior to resection (n = 3). There were no grade 3 toxicities following neoadjuvant chemoradiation treatment. Eleven patients (41%) had additional neoadjuvant chemotherapy prior to surgery; most commonly with FOLFOX (n = 6) or CAPOX (n =4.) Seventeen patients (63%) underwent surgical resection; most commonly Low Anterior Resection (n= 10), Abdominal Perineal Resection (n = 6). Twelve patients (44%) received adjuvant chemotherapy, most commonly FOLFOX (n = 10). Our single-institution retrospective analysis demonstrates that early-onset rectal cancer afflicts almost equally men and women, mostly non-smokers, in their early 40s. These patients predominantly present with rectal bleeding. Most patients received standard neoadjuvant chemoradiation followed by definitive resection and adjuvant chemotherapy, but alternative strategies such as neoadjuvant chemotherapy were often employed. Further study comparing this growing clinical cohort is needed.

Safety and efficacy of synchronous robotic surgery for colorectal cancer with liver metastases.

Timing of resection and treatment of colorectal cancer (CRC) with liver metastases varies based on patient characteristics and center protocols. Concerns of increased morbidity and mortality (M&M) related to anesthetic time and blood loss have limited widespread adaptation of synchronous colorectal and liver resections. Furthermore, technical challenges have made minimally invasive synchronous resections less common. We present our series of synchronous robotic surgery for CRC with liver metastases. Retrospective review of prospectively collected data of patients with stage IV CRC with liver metastases treated at a tertiary center from February 2013 to June 2014. Patients who underwent synchronous robotic surgery for CRC with liver metastasis(es) were included and selected by a multidisciplinary cancer committee. Data included patient demographics, disease stage, OR time, EBL, and complications. All resections were performed robotically by the same well-experienced surgeons. A radiologist was present for intraoperative ultrasound. Liver treatment was performed first in consideration of intraoperative bleeding risk. Sixty-six patients with Stage IV CRC were seen at the tertiary center during the study period. Six patients met inclusion criteria (2 male, 4 female). Mean age was 59.3 years and mean BMI was 23.46. Mean of 2.25 liver segments were resected and mean of 1.75 liver segments were ablated. Four patients underwent metastatectomy; three with concurrent microwave ablation. One patient had ablation without resection and another had no identifiable lesion on ultrasound. The colonic resections included 3 low anterior resections, 2 abdominal perineal resections (APR), and 1 right hemicolectomy. Mean operative time was 401min (349-506min) with mean EBL of 316mL (150-1000mL). No conversions to an open approach occurred. Median length of stay (LOS) was 4.5 days (3-10days). Complications included delayed wound healing after an APR and a delayed rectal anastomotic failure after ileostomy reversal. There was no 30-day mortality. At a mean follow-up of 19months, one death occurred at 26months and the remaining patients had documented metastatic disease. Synchronous resection for metastatic CRC carries risks. We report our series of synchronous robotic surgery for CRC with liver metastases. The robotic approach contributed to low blood loss, appropriate LOS, and no 30-day mortality. Morbidity experienced was consistent with the procedures and not related to the robotic technique. This series supports the potential benefits of synchronous resection from a technical standpoint. Further data are required to determine treatment and survival benefits. Limitations include small number and retrospective review of data.

Trends in the treatment of rectal prolapse: a population analysis.

Rectal prolapse is a common condition, with conflicting opinions on optimal surgical management. Existing literature is predominantly composed of case series, with a dearth of evidence demonstrating current, real-world practice. This study investigated recent national trends in management of rectal prolapse in the Republic of Ireland (ROI). This population analysis used a national database to identify patients admitted in the ROI primarily for the management of rectal prolapse, as defined by the International Classification of Diseases, 10th Revision (ICD-10). Demographics, procedures, comorbidities, and outcomes were obtained for patients admitted from 2005 to 2015 inclusive. There were 2648 admissions with a primary diagnosis of rectal prolapse; 39.3% underwent surgical correction. The majority were treated with either a perineal resection (47.2%) or an abdominal rectopexy ± resection (45.1%). The population-adjusted rate of operative intervention increased over the study period, from 25 to 42 per million (p < 0.001), with no change in the mean age of patients over time (p = 0.229). The application of a laparoscopic approach increased over time (p = 0.001). Patients undergoing an abdominal rectopexy were younger than those undergoing a perineal procedure (64.1 ± 17.3 versus 75.2 ± 15.5years, p < 0.001) despite having a similar Charlson Comorbidity Index (p = 0.097). The mortality rate for elective repair was 0.2%. Despite the popularization of ventral mesh rectopexy over the study period, perineal resection Delorme's procedure remains the most common procedure employed for the correction of rectal prolapse in the ROI, with specific approach determined by age.

Managing Anaesthesia for Abdomino Perineal Resection in a Hypothyroid Patient with Carcinoma Rectum- The Turmoil Unmasked

Managing Anaesthesia for Abdomino Perineal Resection in a Hypothyroid Patient with Carcinoma Rectum- The Turmoil Unmasked

Tumor location is an independent predictive factor for distant metastasis and metastatic sites of rectal adenocarcinoma in patients receiving total mesorectal excision.

Background and Objectives: To evaluate the predictive factor for and patterns of distant metastasis in patients with rectal adenocarcinoma receiving total mesorectal excision (TME).Methods: We enrolled 217 consecutive patients who had histologically confirmed rectal adenocarcinoma and underwent surgery at Taipei Medical University- Wanfang Hospital between January 2000 and December 2014. TME was performed in all patients undergoing a sphincter-sparing procedure or abdominal perineal resection of rectal cancer. We performed univariate and multivariate Cox regression analyses of the distant metastasis rate in all patients to evaluate predictive factors. Overall survival (OS) rates were calculated using the Kaplan-Meier method, and Kaplan-Meier survival curves were compared using the log-rank test.Results: A multivariate Cox regression analysis of the distant metastasis rate in patients with rectal adenocarcinoma identified tumor locations and American Joint Committee on Cancer (AJCC) stages as prognostic risk factors. The adjusted hazard ratios (aHRs) of distant metastasis for the upper-third, middle-third, and AJCC stage I-II cancers were 0.08 (95% CI, 0.01-0.69; p = 0.021), 0.41 (95% CI, 0.15-0.99; p = 0.047), and 0.20 (95% CI, 0.10-0.66; p = 0.008), respectively. The 5-year lung metastasis rates among patients with upper-, middle-, and lower-third rectal cancers were 0%, 3.37%, and 13.33%, respectively (log-rank, p = 0.001), and the 5-year liver metastasis rates among patients with upper-, middle-, and lower-third rectal cancers were 2.12%, 9.10%, and 11.76%, respectively (log-rank, p = 0.096). The 5-year OS rates also differed with different rectal adenocarcinoma locations. The 5-year OS rates for upper, middle, and lower rectal cancers were 96%, 86%, and 64%, respectively (log-rank, p < 0.001).Conclusion: A poor OS rate and high lung or liver metastasis rate were observed in distal rectal adenocarcinoma. Longer intensive surveillance of the chest, abdomen, and pelvis after TME in distal rectal adenocarcinoma could be necessary.

Organ sparing surgery for rectal cancer: functional outcome and quality of life

Total mesorectal excision (TME) with anterior rectal resection or abdominal perineal resection after neoadjuvant radio-chemotherapy, represents the standard of care for patients with advanced rectal cancer (1,2).

Organ sparing surgery for rectal cancer: functional outcome and quality of life

Total mesorectal excision (TME) with anterior rectal resection or abdominal perineal resection after neoadjuvant radio-chemotherapy, represents the standard of care for patients with advanced rectal cancer (1,2).

Whole-Gland Prostate Cancer Cryoablation with Magnetic Resonance Imaging Guidance: One-Year Follow-Up

Patients who develop prostate cancer after prior abdominal perineal resection are poor surgical candidates, and have limited treatment options. Therefore, our goal is to present results from a single institutional experience of four patients who underwent whole gland MRI-guided cryoablation with a history complicated by prior abdominoperineal resection. Four MRI-guided cryoablative treatments (mean age 64, range 59-69 years) for primary and locally recurrent prostate adenocarcinoma were retrospectively reviewed in patients with prior abdominal perineal resection for colorectal cancer (3) and juvenile polyposis (1). Average prostate volume prior to ablation was 23 cc, with an average PSA of 5.6 ng/mL. For each gland, 7-10 cryoprobes were placed approximately 0.5 cm apart in the prostate gland under MRI guidance by a transperineal approach with 3-4 freeze-thaw cycles performed. Each patient had follow up imaging and PSA measurements out to 12 months post ablation. All four patient's PSA dropped below 0.1 ng/mL at 3-6 month post-ablation and remained at these levels at 12 months. Three of the 4 patients had PSA measurements to 33 months post-ablation, with no evidence of recurrence. No patient developed urinary incontinence due to the whole gland cryoablation. With all four patients in our study having undetectable PSAs 12 months post ablation, and with no patient developing urinary incontinence due to the cryoablation, MRI-guided cryoablation appears to be a promising treatment option in patients who are poor surgical candidates due to prior pelvic surgery and/or radiation.

Multiple rapidly growing desmoid tumors that were difficult to distinguish from recurrence of rectal cancer

BackgroundIntra-abdominal desmoid tumors are usually slow growing and solitary, but multifocal desmoid tumors develop on rare occasions. Diagnosing desmoid tumors before histological examination of a surgical biopsy is often difficult. In particular, if a patient has a prior history of malignancy, it may be difficult to differentiate between these lesions and disease recurrence or metastasis.Case presentationWe present a rare case of multiple rapidly growing intra-abdominal desmoid tumors after surgical trauma, without familial adenomatous polyposis. A 51-year-old male underwent abdominal perineal resection with lateral lymph node dissection after neoadjuvant chemotherapy for lower rectal cancer. Follow-up computed tomography (CT), performed 6 months after primary surgery, showed a 20-mm solitary mass in the pelvic mesentery. Another CT scan, performed 3 months later, revealed that the mass had grown to 35 mm in size and that two new masses had formed. Based on imaging studies and his medical history, it was difficult to distinguish the desmoid tumors from recurrence of rectal cancer. Curative resection was chosen for therapeutic diagnosis. The pathological diagnosis was multiple mesenteric desmoid tumors.ConclusionsDesmoid tumors should not be excluded as a differential diagnosis for intra-abdominal masses after intra-abdominal surgery, even in cases of rapidly growing multiple masses.

Clinical Profile of Carcinoma Rectum and Treatment Modalities with Outcome– An Observational Study

Aim : To determine the incidence of age, sex, clinical manifestations, site, stages of carcinoma rectum and morbidities, mortality following surgery. To evaluate surgical modalities and neoadjuvant chemoradiation in carcinoma rectum. Materials and Methods: This study has been conducted in the Department of Surgery, Govt. Rajaji Hospital, Madurai during 2009- 2011. All patients underwent clinical examination and appropriate investigations to confirm and stage the disease. Patients who were included in neo adjuvant therapy, chemo radiation and surgery were followed. Postoperative adjuvant chemotherapy was also given. Patients were followed up for 1 year. Results: Out of 50, majority of carcinoma rectum cases occurs in 5th decade (28%) with male:female ratio 2:1. The predominant symptoms were bleeding per rectum(76%),constipation(58%) and pain(24%). Commonest site was lower 1/3rd of rectum(54%). Majority of the patients were in stage III( 48%),stage I and II(36%)and stageIV(8%). 20 patients underwent abdomino perineal resection(44%), 10 patients underwent laproscopic assisted abdomino perineal resection(22%), 7 patients underwent anterior resection(16%),8 patients underwent emergency colostomy and 5 patients were inoperable for whom palliative chemotherapy / radiotherapy was given. Neo adjuvant chemoradiation was given in 5 patients with stage III. Out of which anterior resection was done in 3 patients(60%) and APR was done in 2 (40%). The most common post operative morbidity was perineal wound infection(16.6%),Perineal wound gaping( 3.3%), Abdominal wound infection( 2.2%). Retention of urine in 2 patients and impotence in 1 patient. Less postoperative complications were noted with inceasing age of the patients(P

Recurrence with pagetoid spread arising 17\xa0years after surgery for intramucosal rectal cancer: a case report

BackgroundPerianal Paget’s disease (pPD) is uncommon, with only about 180 cases documented in the literature. Anorectal carcinoma with pagetoid spread is even rarer.Case presentationAn 81-year-old woman underwent rectal cancer extirpation with a transanal approach 17 years prior. She has since undergone two reoperations for local rectal cancer recurrence. Then, warts frequently appeared on the vulva on several occasions. Warts appeared on the vulva 1 year ago, which were diagnosed as pPD by biopsy. She underwent perineal tumor resection, and the final histological diagnosis was rectal cancer recurrence with pagetoid spread. The resected stump was positive for cancer cells, and tumor progression was rapid. She underwent additional abdominoperineal resection (Miles’ operation) with lymph node dissection. However, disease progression was rapid and she died 7 months after the Miles’ operation.ConclusionsThere are some case reports describing anorectal carcinoma with pagetoid spread, however, almost of all those cases were synchronous primary anorectal cancer. Here, we report the first case of metachronous recurrence rectal cancer with pagetoid spread arising 17 years after surgery.

Clinical efficacy of laparoscopic extralevator abdominoperineal excision for low rectal cancer without turning position

Objective To explore the clinical efficacy of laparoscopic extralevator abdominoperineal excision (laparoscopic ELAPE) for low rectal cancer with modified Lloyd-Davies lithotomy position and without turning position. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 27 patients with low rectal cancer who underwent laparoscopic ELAPE without turning position in the West China Hospital of Sichuan University from September 2013 to January 2015 were collected. The modified Lloyd-Davies lithotomy position was used in perineal resection. Observation indicators: (1) surgical situation; (2) postoperative recovery situation; (3) postoperative pathological examination situation; (4) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications, survival of patients and tumor recurrence or metastasis up to March 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Surgical situation: A total of 27 patients received laparoscopic ELAPE without turning position, and operation time and volume of intraoperative blood loss were (198±51)minutes and (85±66)mL. Among 5 of 27 patients with intraoperative complications, 1 with intestinal perforation received successful intraoperative repair, 1 with presacral haemorrhage received successful hemostasis by intraoperative gauze pressing, 1 with left and right pelvic plexus injury didn′t receive special treatment, 1 with left pelvic plexus injury + left internal iliac vein injury didn′t receive special treatment and were repaired in vascular injury repair, 1 with right neurovascular bundle injury didn′t receive special treatment of nerve injury and received successful hemostasis by ultrasonic scalpel. There was no perforation in the site of the tumor. Number of lymph node dissected was 14 (range, 9-22), and number of lymph node dissected ≥12 and 100 mL) and 7 in Clavien-DindoⅡ (3 with pulmonary infection, 2 with chylous fistula, 1 with perineal incision infection and 1 with hematuria). There was no death within 30 days postoperatively. The median duration of hospital stay of 27 patients was 7 days (range, 6-8 days). (3) Postoperative pathological examination situation: of 27 patients, 1 and 26 had respectively positive and negative circumferential margins and median distance of circumferential margin was 0.7 cm (range, 0.1-1.1 cm). T stage: 14, 12 and 1 patients were respectively detected in T2, T3 and T4. N stage: 18, 6 and 3 patients were respectively found in N0, N1 and N2. (4) Follow-up and survival situations: 25 of 27 patients were followed up for 2-32 months, with a median time of 24 months. During the follow-up, 5 had complications after discharge from hospital. Of 5 patients, 2 with persistent anal pain didn′t receive special treatment and were not relieved, and 3 with sexual dysfunction didn′t receive special treatment and were followed up or observed. Of 25 patients, 2 died of tumor-related diseases, 1 died of non-tumor-related disease and other 22 had survival. No local tumor recurrence was detected. Eight patients had tumor distant metastases, including 4 with pulmonary metastases, 3 with hepatic metastases and 1 with brain metastasis. Conclusion Laparoscopic ELAPE by modified Lloyd-Davies lithotomy position without turning position is safe and feasible, with closing pelvic floor peritoneum in stage Ⅰ. Key words: Rectal neoplasms, low; Extralevator abdominoperineal excision; Laparoscopy; Position

Outcomes of different surgical approaches and prognostic factors of T1 rectal cancer with distance from anal verge ≤8.0 cm

Objective To investigate the clinical outcomes of transanal local excision (LE) and transabdominal radical surgery (RS) for T1 rectal cancer with distance from anal verge (DAV) ≤8.0 cm, and analyze the prognostic factors after non-palliative resection of T1 rectal cancer with DAV ≤8.0 cm. Methods The retrospective cohort study was conducted. The clinicopathological data of 82 T1 rectal cancer patients with DAV ≤8.0 cm who were admitted to the Fujian Medical University Union Hospital between December 2000 and December 2014 were collected. Among 82 patients, 42 undergoing transanal LE and 40 undergoing transabdominal RS were allocated into the LS and RS groups, respectively. Forty-two patients in the LE group received transabdominal RS or postoperative adjuvant radiochemotherapy if results of postoperative pathological examination showed high risk. Observation indicators: (1) comparisons of surgical and postoperative situations between the 2 groups; (2) follow-up situations; (3) prognostic factors analysis after non-palliative resection of T1 rectal cancer with DAV ≤8.0 cm. Follow-up using outpatient examination and telephone interview was performed to detect the defecation and sexual functions, survival and tumor recurrence up to January 2017. Measurement data with normal distribution were represented as ±s, and comparisons between groups were evaluated with an independent sample t test. Comparisons of count data were analyzed using the chi-square test or Fisher exact probability. The Kaplan Meier method was used for calculating overall survival rate and tumor-free rate, and survival was analyzed using the Log-rank test. Multivariate analysis was done using the COX regression model. Results (1) Comparisons of surgical and postoperative situations between the 2 groups: all the 82 patients underwent successful surgery. Of 42 patients in the LE group, 28 underwent single transanal LE, 2 underwent additional transabdominal RS within 1 month postoperatively, 6 underwent postoperative adjuvant radiochemotherapy, 5 underwent postoperative adjuvant radiotherapy and 1 underwent postoperative adjuvant chemotherapy (didn′t complete course due to poor tolerance). Forty patients in the RS group underwent transabdominal anterior resection of rectum or combined with abdominal perineal resection for rectal cancer. DAV, operation time, volume of intraoperative blood loss, time of postoperative gastrointestinal function recovery, cases with pulmonary infection and duration of postoperative hospital stay were (4.9±1.3)cm, (65±33)minutes, (11±7)mL, (1.2±0.4)days, 0, (2.2±0.9)days in the LE group and (6.7±1.9)cm, (256±35)minutes, (65±47) mL, (2.4±0.8)days, 6, (6.9±1.1)days in the RS group, respectively, with statistically significant differences (t=4.882, 12.448, 3.553, 4.025, χ2=6.797, t=10.367, P 0.05). All patients with complications were cured by conservative treatment. (2) Follow-up situations: of 82 patients, 67 were followed up for defecation function (37 in the LE group and 30 in the RS group), 40 were followed up for sexual function (25 in the LE group and 15 in the RS group), 76 were followed up for survival. Follow-up time was 1-145 months, with a median time of 31 months. Cases with fecal incontinence and sexual dysfunction were respectively 0, 0 in the LE group and 4, 3 in the RS group, showing statistically significant differences (χ2=5.247, 5.405, P 0.05). (3) Prognostic factors analysis after non-palliative resection of T1 rectal cancer with DAV ≤8.0 cm: results of multivariate analysis showed that age was an independent factor affecting prognosis of T1 rectal cancer patients with DAV ≤8.0 cm after non-palliative resection (RR=1.254, 95% confidence interval: 1.055-1.491, P<0.05). Conclusions Transanal LE in treatment of T1 rectal cancer patients with DAV ≤8.0 cm is consistent with RS in local control and long term prognosis, and the protection of defecation and sexual functions in LE is superior to that in RS. Age is an independent factor affecting prognosis of T1 rectal cancer patients with DAV ≤8.0 cm after non-palliative resection. Key words: Rectal neoplasms, T1; Local excision; Radical resection; Prognosis

Resident Operative Experience at Independent Academic Medical Centers—A Comparison to the National Cohort

Independent Academic Medical Centers (IAMCs) comprise one-third of U.S. general surgery training programs. It is unclear whether IAMCs offer qualitatively or quantitatively different operative experiences than the national cohort. We analyzed a large representative sample of IAMCs to compare operative volume and variety, with a focus on low-volume procedures. Accreditation Council for Graduate Medical Education Program Case Reports from 27 IAMCs were collected and analyzed for 3 academic years (2012-2015). IAMCs were compared to the national cohort for specific defined category volumes and selected low-volume cases. One-sample two-way t-tests were calculated comparing IAMC totals to national program averages. IAMCs had a median of 3 chief residents per year (range: 1-6). IAMCs reported significantly more "total major" procedures in 2013-2014 (p = 0.046). Other case totals were statistically similar between IAMCs and the national cohort for "total major", "surgeon chief", "surgeon junior", and "teaching assistant" cases. In 2013-2014, IAMCs reported more laparoscopic complex (138.3 vs. 110.6, p = 0.010) and alimentary tract cases (276.5 vs. 253.5, p = 0.019). IAMC esophagogastroduodenoscopy case totals were higher in 2013-2014 (55.9 vs. 41, p = 0.038) and 2014-2015 (47.8 vs. 41, p = 0.047). IAMCs had fewer pancreas cases than the national cohort in all three years by about three cases per resident (p ≤ 0.026). In 2012-2013 IAMCs reported fewer (by about one) esophagectomy, gastrectomy, and abdominal perineal resections. No differences were observed in the following selected procedures: open common bile duct exploration, inguinal hernia, laparoscopic appendectomy, laparoscopic cholecystectomy, and colonoscopy. The IAMCs studied appear to provide equivalent exposure to specific subcategories mandated by the Accreditation Council for Graduate Medical Education and American Board of Surgery. Graduates of IAMCs gain similar operative experience in low-volume, defined categories when compared to the national cohort. Certain specific cases subject to regionalization pressure are less well represented among IAMCs. This has important implications for medical students applying to surgery residency.

When to Assess Treatment Response in Anal Cancer

Standard therapy for anal squamous cancer combines chemotherapy with infusional 5-fluorouracil, mitomycin, and radiation therapy without surgery. The recommended time to assess response is 6 to 12 weeks after initiation of chemoradiotherapy. Patients with incomplete response are referred for salvage abdominal perineal resection. To evaluate the optimal timing of assessment of clinical response to chemoradiotherapy in anal squamous cancer, investigators in the U.K. have conducted a retrospective analysis of the …

Right Colectomy and Abdominal Perineal Resection for Cancer: Do Urinary Tract Infections Impact Outcomes?

We aim to assess the patient factors and concomitant infectious outcomes associated with urinary tract infection (UTI) occurrence and the impact of UTI on length of stay (LOS), re-admission, and death in a colorectal surgical population. National Surgical Quality Improvement Program User Data for right colectomy and abdominal perineal resection (APR) procedures for cancer between 2006 and 2012 were analyzed. Concomitant infectious complications and timing of UTI diagnosis, inpatient versus outpatient, were considered. We identified 7,615 right colectomies with 107 (1.4%) UTIs and 2,493 APRs with 88 (3.5%) UTIs (p < 0.001). On multivariable analysis and correction for other post-operative complications, UTI remained statistically correlated with prolonged LOS for right colectomy and APR (LOS increases of 59.0% and 37.4%, respectively, p < 0.001) but not death. Patients with a diagnosis of UTI after discharge showed significantly increased re-admission rates compared with UTI diagnosis before discharge (37.7% vs. 9.7%, p < 0.001). After excluding deaths, outpatient UTI occurrences, and correcting for other infectious complications, UTI is associated with increased LOS but is not correlated with re-admission or death. Outpatient occurrence of UTI after hospital discharge is associated with a dramatic re-admission rate of 37.7%.

Transumbilical abdominal incision for laparoscopic colorectal surgery does not increase the risk of postoperative surgical site infection.

Besides antibiotic prophylaxis, antiseptic skin preparation is an important measure to prevent surgical site infection (SSI). No reports have detailed the relationship between SSI and umbilical microflora following laparoscopic colorectal cancer with a transumbilical longitudinal incision. Risk factors and the rate of SSI were investigated in 453 patients who underwent laparoscopic colorectal resection over a 3-year period. Microbiological samples were collected from the umbilicus and SSI areas. After laparoscopic procedure, we observed SSIs in approximately 5% of cases, with superficial SSI in 15 (3.3%) patients and organ/space SSIs 7 (1.5%). In univariate analysis, preoperative albumin (Alb) value and anastomosis of enterocolostomy were significantly associated with superficial SSI development. Also, age, blood loss, stoma, tumor site (rectum), and Hartmann/abdominal perineal resection (APR) were significant risk factors for organ/space SSI. In multivariate analysis, the preoperative Alb value was the most significant factor associated with a predisposition to superficial SSI. The bacteria detected in SSI were mostly different from those at wound closure. Antibiotic-resistant bacteria were included in organ/space SSI all cases. SSI development with laparoscopic surgery reportedly occurs in about 3-15% cases. The SSI rate in this study and other reports was comparable. Using small transumbilical longitudinal incision in laparoscopic colorectal surgery is less likely to cause SSI when sufficient control measures are enacted, even though the umbilicus contains resident bacteria in abundance.