Do the advantages of a minimally invasive approach remain in complex colorectal procedures? A nationwide comparison.

BACKGROUND: Since the introduction of laparoscopic colectomy, experience and technology continue to improve. Although accepted for many colorectal conditions, its use and outcomes in complex procedures are less understood. OBJECTIVE: The purpose of this work was to compare the perioperative outcomes of laparoscopic transverse colectomy and total abdominal colectomy (study group) with an open approach (comparative group) and the more established laparoscopic right, left, and sigmoid colectomies (control group). DESIGN: This was a retrospective review of the Nationwide Inpatient Sample (2008-2011) of all patients undergoing elective right, left, sigmoid, total, or transverse colectomy as identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Risk-adjusted 30-day outcomes were assessed using regression modeling accounting for patient characteristics, comorbidities, and surgical procedures. SETTINGS: The study included a national sample from a population database. PATIENTS: There were 45,771 admissions: 2946 in the study group, 36,949 in the control group, and 5876 in the open comparative group. MAIN OUTCOME MEASURES: Mortality was the primary outcome. Secondary outcomes included in-hospital complications, length of stay, and hospital charges. RESULTS: The patients were predominantly white (73%), had private insurance (64%), and underwent surgery at urban centers (92%). Mortality was similar between the study and control groups (0.42% vs 0.51%; p = 0.52), with a higher complication rate in the study group (19% vs 14%; p < 0.01). The study group was also associated with a lower mortality rate compared with the open group (0.51% vs 2.20%; p < 0.01), which remained consistent after adjusting for covariates (OR, 0.38 [95% CI, 0.20-0.71]; p < 0.01). The study group had fewer complications overall compared with the open group (19% vs 27%; p < 0.01) and a shorter median length of stay (4.6 vs 6.3 days; p < 0.01). LIMITATIONS: This was a retrospective study using an administrative database. CONCLUSIONS: A laparoscopic approach for total abdominal and transverse colectomies has similar mortality rates and slightly higher complications than the more established laparoscopic colectomy procedures and improved perioperative outcomes when compared with an open technique (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A178).

A population-based comparison of open versus minimally invasive abdominoperineal resection.

BACKGROUND: Although minimally invasive colorectal surgery increases widely, outcomes following its use in complex operations such as the abdominoperineal resection (APR) remain indeterminate. METHODS: A review of the Nationwide Inpatient Sample (2008 to 2011) of all patients undergoing elective laparoscopic or open APR was conducted. Risk-adjusted 30-day outcomes were assessed using regression modeling accounting for patient characteristics, comorbidities, and surgical procedure. RESULTS: We identified 3,191 admissions meeting inclusion criteria (1,019 laparoscopic; 2,172 open). The conversion rate was 5%. Mortality was low and similar between groups (.88% vs .83%, P = .91). In-hospital complication rates were lower in the laparoscopic group (19% vs 29%, odds ratio .59, 95% confidence interval .49 to .71, P < .01), but conversion was associated with a higher rate (29% vs 18%, P < .01). Finally, a laparoscopic APR was associated with a shorter length of stay (5.3 vs 7.0 days, P < .01). CONCLUSION: Laparoscopic APR is associated with improved outcomes and may be the preferred approach by surgeons with appropriate skills and experience.

Improving outcomes and cost-effectiveness of colorectal surgery.

In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.

Prophylactic antibiotics for hemorrhoidectomy: are they really needed?

BACKGROUND: Hemorrhoidectomy is considered by many to be a contaminated operation that requires antibiotic prophylaxis to lower the incidence of surgical site infection. In reality, little evidence exists to either support or refute the use of antibiotic prophylaxis in this setting. OBJECTIVE: This study aimed to determine if antibiotic prophylaxis is associated with reduced incidence of postoperative surgical site infection following hemorrhoidectomy. DESIGN: This is a retrospective database review. SETTING: This study was conducted at multiple institutions. PATIENTS: All patients undergoing hemorrhoidectomy with minimum 3-month follow-up were included. MAIN OUTCOME MEASURES: The primary outcome measure was the incidence of postoperative surgical site infection. RESULTS: Eight hundred fifty-two patients met the inclusion criteria (50.1% female; mean age, 50.0 ± 13.7 years). The prevalence of preoperative risk factors for surgical site infection included 7.7% with a smoking history, 2.5% with diabetes mellitus, 0.8% receiving steroids, and 0.2% with Crohn's disease. Surgery was performed predominately for 3-column prolapsed internal and mixed internal/external hemorrhoidal disease. All surgeries performed were closed hemorrhoidectomies. Antibiotic prophylaxis was used in a fewer number of cases (41.3% vs 58.7%). Overall, there were only 12 documented postoperative infections identified, producing an overall incidence of 1.4%. Of those patients who developed postoperative surgical site infections, 9 (75%) did not receive antibiotic prophylaxis (p = 0.25). On multivariate regression analysis, no perioperative risk factor was associated with an increased risk of developing a posthemorrhoidectomy surgical site infection. Conversely, there were no adverse antibiotic-related complications such as Clostridium difficile colitis or antibiotic-associated diarrhea in those receiving antibiotic prophylaxis. LIMITATIONS: This study was limited by the retrospective nature of the analysis. CONCLUSIONS: Postoperative surgical site infection is an exceedingly rare event following hemorrhoidectomy. Antibiotic prophylaxis does not reduce the incidence of postoperative surgical site infection, and its routine use appears unnecessary.

Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection.

BACKGROUND: During the past 20 years, laparoscopy has revolutionized colorectal surgery. With proven benefits in patient outcomes and healthcare utilization, laparoscopic colorectal surgery has steadily increased in use. Robotic surgery, a new addition to colorectal surgery, has been suggested to facilitate and overcome limitations of laparoscopic surgery. Our objective was to compare the outcomes of robot-assisted laparoscopic resection (RALR) to laparoscopic resections (LAP) in colorectal surgery. METHODS: A national inpatient database was evaluated for colorectal resections performed over a 30-month period. Cases were divided into traditional LAP and RALR resection groups. Cost of robot acquisition and servicing were not measured. Main outcome measures were hospital length of stay (LOS), operative time, complications, and costs between groups. RESULTS: A total of 17,265 LAP and 744 RARL procedures were identified. The RALR cases had significantly higher total cost ($5,272 increase, p < 0.001) and direct cost ($4,432 increase, p < 0.001), significantly longer operating time (39 min, p < 0.001), and were more likely to develop postoperative bleeding (odds ratio 1.6; p = 0.014) than traditional laparoscopic patients. LOS, complications, and discharge disposition were comparable. Similar findings were noted for both laparoscopic colonic and rectal surgery. CONCLUSIONS: RALR had significantly higher costs and operative time than traditional LAP without a measurable benefit.

The impact of Model for End-Stage Liver Disease-Na in predicting morbidity and mortality following elective colon cancer surgery irrespective of underlying liver disease.

BACKGROUND: The Model for End-Stage Liver Disease Sodium Model (MELD-Na) is a validated scoring system that uses bilirubin, international normalized ratio, serum creatinine, and sodium to predict mortality in cirrhotic patients awaiting liver transplantation. The aim of this study was to identify the utility of MELD-Na to predict patient outcomes, with and without liver disease, after elective colon cancer surgery. METHODS: A review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2010) was conducted to calculate risk-adjusted 30-day outcomes using regression modeling. RESULTS: A total of 10,842 patients (mean age, 68 years; 51% women) were included. MELD-Na scores were higher in men (10.2 vs 9.1, P < .001) and in open procedures (9.9 vs 9.1, P < .001). The overall complication and mortality rates were 26.3% and 3.3%, respectively. Incremental increases in MELD-Na score correlated with a 1.2% increase in mortality and a 1.1% increase in complications. On multivariate analysis, complications increased with MELD-Na score (odds ratio [OR], 1.05 per 1 point increase; 95% confidence interval [CI], 1.038 to 1.066). MELD-Na score was also associated with increased mortality (OR, 1.13; 95% CI, 1.1 to 1.16), along with ascites (OR, 5.7; 95% CI, 3.7 to 8.8) and corticosteroids (OR, 2.1; 95% CI, 1.3 to 3.3). CONCLUSIONS: Elevated preoperative MELD-Na score is significantly associated with worse outcomes after elective resection for colon cancer.

The impact of race on outcomes following emergency surgery: an American College of Surgeons National Surgical Quality Improvement Program assessment.

BACKGROUND: Despite significant evolutions in health care, outcome discrepancies exist among demographic cohorts. We sought to determine the impact of race on emergency surgery outcomes. METHODS: This is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 through 2009) for all patients aged ≥16 years undergoing emergency abdominal surgery. Primary outcomes included morbidity and mortality. RESULTS: We identified 75,280 patients (mean age 48.2 ± 19.9 years, 51.7% female; 79% white, 9.9% black, 5.0% Hispanic, 3.7% Asian, 1.3% American Indian or Alaskan, .2% Pacific Islander). Annual rates of emergency operations ranged from 7.3% to 8.5% (P = .22). The overall complication (18.6%) and mortality rate (4.6%) was highest in the black population (24.3%, 5.3%) followed by whites (18.7%, 4.6%), with the lowest rate in Hispanic (11.7%, 1.8%) and Pacific Islander populations (10.2%, 1.8%; P < .001). Compared with whites, blacks had a 1.25-fold (1.17 to 1.34; P < .001) increased risk of complications, but similar mortality (P = .168). When combining minorities, overall complications were 1.059-fold (1.004 to 1.12; P = .034) higher, however, mortality was reduced 1.7-fold (1.07 to 1.34; P = .001). CONCLUSIONS: Following emergency abdominal surgery, minority race is independently associated with increased complications and reduced mortality.

Considerations and complications in patients undergoing ileal pouch anal anastomosis.

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

An NSQIP evaluation of practice patterns and outcomes following surgery for anorectal abscess and fistula in patients with and without Crohn's disease.

BACKGROUND: Patients with Crohn's disease (CD) are believed to have more aggressive anorectal abscess and fistula disease. We assessed the types of procedures performed and perioperative complications associated with the surgical management of anorectal abscess and fistula disease in patients with and without CD. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP, 2005-2010) was used to calculate 30-day outcomes using regression modeling, accounting for demographics, comorbidities and surgical procedures. ICD-9 codes for anorectal abscess or fistula were used for initial selection. Patients were then stratified, based on the presence or absence of underlying CD. Local procedures included incision and drainage of abscesses, fistulotomy and seton placement. Cutaneous fistulas were considered simple, while all others were classified as complex (-vaginal, -urethral and -vesical). RESULTS: A total of 7,218 patients (mean age 45 years; 64% male) met inclusion criteria, with underlying CD in 345 (4.8%). CD patients were more likely to have a seton placed (9.9 vs 8.2%, P < 0.001) and be on steroids (15.4 vs 4.3%, P < 0.001). Thirty-seven percent of CD patients underwent local procedures, while 46% had a proctectomy and 8% underwent diversion. Fistulotomy was more common in those without underlying CD (16 vs 11%, P < 0.001). The overall complication rate after local treatment was 4.9%, with no difference between patients with and without CD (7.7 vs 4.9%, P = 0.144). This was not affected by fistula type-simple (7.9 vs 3.9%, P = 0.194) vs complex (33 vs 7.1%, P = 0.21)-or when stratified by wound (3.8 vs 2.4%; P = 0.26) or systemic complications (3.8 vs 2.5%; P = 0.53). Yet, complications following emergency procedures were higher in patients with CD (21.4 vs 5.9%, P = 0.047). Factors significantly associated with increased complications were Crohn's disease (OR = 8.2), lack of functional independence (OR = 2.0), pre-operative weight loss (OR = 2.6) and pre-operative acute renal failure (OR = 5.6). Steroids were also associated with a 1.7-fold increase in complications, independent from CD. CONCLUSIONS: While most patients with anorectal abscess/fistula are treated with local procedures, proctectomy and diversion use is fairly common in those with underlying CD. Although complication rates following elective local procedures for anorectal abscess/fistula are similar in patients with and without CD, they are higher in patients on steroids and in CD patients undergoing emergent procedures.

Alvimopan for acceleration of GI recovery after bowel resection.

Nurses play a critical role in the management of postoperative ileus during the perioperative phase of recovery. Alvimopan is an oral, peripherally acting, mu-opioid receptor antagonist that accelerates time to gastrointestinal recovery (resolution of postoperative ileus), representing a potential advance in management of these patients.

Surgical therapy for epidermoid carcinoma of the anal canal: an NSQIP assessment of short-term outcomes.

BACKGROUND: Although modern therapy for anal canal cancer typically consists of combined chemoradiation therapy (CRT), surgery remains an option for patients with small lesions, for palliative purposes, and for failure of nonoperative management. This study assesses the short-term outcomes of surgical management for epidermoid carcinoma of the anal canal using a large nationwide database. METHODS: We performed a retrospective review of 30-d outcomes using American College of Surgeons National Surgical Quality Improvement Program database (2005-2009) for all patients with the primary diagnosis of anal canal cancer undergoing oncologic or palliative surgery. We defined preoperative CRT using standard National Surgical Quality Improvement Program time frames of 30 and 90 d, respectively, before surgery. RESULTS: We identified 295 patients (mean age, 58.6 y; 54% female; 77% white). A total of 34 patients received prior CRT and had age, body mass index, American Society of Anesthesiologists class, and preoperative laboratory values similar to those without CRT; the only significant differences was a lower hematocrit and platelet count in the CRT group. For the entire cohort, 30% (N = 89) underwent local excision (LE), 24% (N = 71) diversion, and 46% (N = 135) abdominoperineal resection (APR). Complications occurred in 23.7% of the entire cohort, and overall complication rates significantly differed based on the type of procedure [3.4% for LE and 18.3% for diversion, versus 40% for APR (P < 0.001)]. Only operative approach significantly affected morbidity, as patients receiving APR had a 1.67-fold (range, 1.14-2.45; P = 0.008) increased risk of complications. The 30-d mortality for the entire cohort was 2.7%, and was highest in the diversion group (7%) compared with the APR (1.5%) and local excision groups (1.1%; P = 0.036). However, by multivariate analysis, the only factors associated with death were preoperative sepsis (hazard ratio [HR] = 27.5; P = 0.005), lack of functional independence (HR = 26.3; P = 0.001), hypertension (HR = 14.4; P = 0.028), and prior alcohol use (HR = 21.4; P = 0.026). Chemoradiation therapy use did not have a significant effect on complication (36.0% versus 40.9%; P = 0.651) or mortality rates (0% versus 1.8%; P = 0.497). CONCLUSIONS: Surgical intervention for anal canal cancer remains a necessary option for select patients. Morbidity rates vary significantly based on the type of treatment; operative approach is the primary factor associated with postoperative short-term complications. When surgery is required, recent CRT is not associated with a higher complication rate. With proper perioperative care and surgical technique, mortality rates remain low, and the increased death rate with diversion, even in the short term, likely represents advanced disease.

International trends in surgical treatment of rectal cancer.

BACKGROUND: Surgical technique might influence rectal cancer survival, yet international practices for surgical treatment of rectal cancer are poorly described. METHODS: We performed a cross-sectional survey in a cohort of experienced colorectal surgeons representing 123 centers. RESULTS: Seventy-one percent responded, 70% are from departments performing more than 50 proctectomies annually. More than 50% defined the rectum as "15 cm from the verge." Seventy-two percent perform laparoscopic proctectomy, 80% use oral bowel preparation, 69% perform high ligation of the inferior mesenteric artery, 76% divert stomas as routine for colo-anal anastomosis, and 63% use enhanced recovery protocols. Different practices exist between US and non-US surgeons: 15 cm from the verge to define the rectum (34% vs 59%; P = .03), personally perform laparoscopic resection (82% vs 66%; P = .05), rectal stump washout (36% vs 73%; P = .0001), always drain after surgery (23% vs 42%; P = .03), transanal endoscopic microsurgery for T2N0 in medically unfit patients (39% vs 61%; P = .0001). CONCLUSIONS: Wide international variations in rectal cancer management make outcome comparisons challenging, and consensus development should be encouraged.

International preoperative rectal cancer management: staging, neoadjuvant treatment, and impact of multidisciplinary teams.

BACKGROUND: Little is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates. METHODS: One hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer. RESULTS: One hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5 years' experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, p = 0.008), CRT for stage II and III rectal cancer (92% vs. 43%, p = 0.0001), MRI for all RC patients (20% vs. 42%, p = 0.03), and ERUS for all RC patients (43% vs. 21%, p = 0.01). Multidisciplinary team meetings significantly influence decisions for MRI (RR = 3.62), neoadjuvant treatment (threatened CRM, RR = 5.67, stage II + III RR = 2.98), quality of pathology report (RR = 4.85), and sphincter-saving surgery (RR = 3.81). CONCLUSIONS: There was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods.

Endoscopic mucosal resection with full-thickness closure for difficult polyps: a prospective clinical trial.

BACKGROUND: Large flat polyps may be more amenable to endoscopic resection if an endoluminal method for full-thickness closure were available. OBJECTIVE: Assessment of feasibility of endoluminal full-thickness closure. DESIGN: Prospective, open-label, interventional study. SETTING: Tertiary referral center. PATIENTS: Patients referred to surgery for endoscopically unresectable polyps. INTERVENTIONS: Endoscopic resection of colon polyps with full-thickness closure of the resection site under laparoscopic observation by using a novel needle and T-tag tissue apposition system. MAIN OUTCOME MEASUREMENTS: Feasibility and efficacy of tissue apposition with the TAS during procedure and safety at 3-month follow-up. RESULTS: Nineteen patients referred with unresectable polyps at initial colonoscopy were enrolled. Five patients had successful endoscopic polypectomy and did not require closure of the resulting defect. In 6 patients, the polyp could not be resected endoscopically and surgical resection was performed. Use of the TAS was attempted in 8 and successfully deployed in 7 patients; there was 1 device malfunction. Deployment of the tags through the needle could be performed more safely under laparoscopic guidance when the resection site was visible from the peritoneal cavity. The location of the tags could not be safely determined when the needle was directed toward the retroperitoneal or mesenteric site. There were no long-term complications. Colonoscopy at a 3-month follow-up showed normal healed mucosa with the sutures and anchoring devices in place. LIMITATIONS: Small number of patients, single-center feasibility study without control arm. CONCLUSIONS: Full-thickness endoluminal closure of large polypectomy sites in humans is feasible for selected difficult polyps. Closure should be performed with concurrent laparoscopic guidance to maximize safety. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT00553436.).

Acute management of stoma-related colocutaneous fistula by temporary placement of a self-expanding plastic stent.

Colocutaneous fistulas are frequently the result of complications related to previous operative procedures and are a major cause of morbidity. Most are initially treated conservatively, with a large percentage eventually requiring further surgery for definitive treatment. The use of a temporary colonic stent for the management of colostomy-related colocutaneous fistula has not been previously described. Two patients with colocutaneous fistula related to end colostomies and opening into midline laparotomy wounds were treated by temporary plastic stenting. A removable Polyflex silicone stent was inserted into the stoma. Stent redeployment was needed on several occasions following partial stent expulsion. Midline wound healing was achieved in both cases by 6 weeks post-stent insertion, and complete fistula closure occurred in 1 case. Temporary stent placement in certain cases may aid in the management of a colocutaneous fistula associated with a colostomy to allow fecal diversion from wounds and aid fistula closure.

Emergency laparoscopic colectomy: does it measure up to open?

BACKGROUND: Laparoscopic colectomy has become the standard of care for elective resections; however, there are few data regarding laparoscopy in the emergency setting. METHODS: By using a database with prospectively collected data, we identified 94 patients who underwent an emergency colectomy between August 2005 and July 2008. Laparoscopic surgeries were performed in 42 patients and were compared with 25 patients who were suitable for laparoscopy but received open colectomy. RESULTS: The groups had similar demographics with no differences in age, sex, or surgical indications. Blood loss was lower (118 vs 205 mL; P < 0.01) and the postoperative stay was shorter (8 vs 11 d; P = 0.02) in the laparoscopic patients, and perioperative mortality rates were similar between the 2 groups (1 vs 3; P = 0.29). CONCLUSIONS: With increasing experience, laparoscopic colectomy is a feasible option in certain emergency situations and is associated with shorter hospital stay, less morbidity, and similar mortality to that of open surgery.

Validation of a novel postoperative quality-of-life scoring system.

BACKGROUND: No specific scoring system exists for the assessment of postoperative quality of life (QOL) after major abdominal surgery. This study prospectively validates PQL, a novel prospective scoring system in patients having laparoscopic or open major abdominal colorectal surgery. METHODS: Six experienced surgeons developed the questionnaire. Twenty patients reviewed and selected the most relevant questions, yielding 14 questions. One hundred patients undergoing a variety of colorectal procedures completed the questionnaire preoperatively, and on postoperative days (POD) 1, 2, 4, 8, 12, 30, and 60. Internal validation was assessed by Cronbach's alpha and factor analysis. RESULTS: Cronbach's alpha revealed excellent internal consistency, ranging from .84 to .94 at all time points, even at POD 1 when Cronbach's alpha was .79, demonstrating that the items in the questionnaire measured the same underlying construct. Factor analysis consistently loaded at each follow-up time on the same 2 factors. CONCLUSIONS: Factor analysis consistently loaded at each follow-up time on the same 2 factors, designated the PQL Symptom Score and the PQL Recover Score.

The feasibility of laparoscopic colectomy in urgent and emergent settings.

BACKGROUND: Laparoscopic colectomy (LC) is slowly becoming the standard of care for elective resections. However, the use of LC in the emergency setting is relatively unstudied. The authors describe their experience with a series of emergent and urgent LC cases for a variety of colorectal pathologies. METHODS: This study reviewed 20 consecutive patients who had a laparoscopic emergent or urgent colectomy over a 2-year period. Patient demographics, indications for surgery, operative details, and postoperative complications were examined. RESULTS: Two cases were converted to open procedure, and the mean operative time was 162 min (median, 163 min). The average postoperative length of hospital stay was 8.1 days (median, 6 days). There was one reoperation and three readmissions within 30 days, with no mortality during the follow-up period. Six patients required intensive care unit (ICU) stays after surgery, and 40% of the patients had one or more postoperative complications. CONCLUSIONS: With increasing experience, LC is a feasible option in nonelective situations. Further prospective and comparative studies will improve our understanding of the outcomes for emergency LC.

Standardized postoperative pathway: accelerating recovery after ileostomy closure.

PURPOSE: In this study we evaluated the outcome of a standardized enhanced recovery program in patients undergoing ileostomy closure. METHODS: Forty-two patients underwent ileostomy closure by a single surgeon and were managed by a standardized postoperative care pathway. On the first postoperative day, patients received oral analgesia and a soft diet. Discharge was based on standard criteria previously published for laparoscopic colectomy patients. Results were recorded prospectively in an Institutional Review Board-approved database, including demographics, operative time, blood loss, complications, length of stay, and readmission data. RESULTS: The median operative time and blood loss were 60 minutes and 17.5 mL, respectively, and median hospital stay was 2 days. Twenty-nine patients (69 percent) were discharged by postoperative Day 2. The complication rate was 23.8 percent; complications included prolonged postoperative ileus (n = 3), early postoperative small-bowel obstruction (n = 1), mortality not related to ileostomy closure (n = 1), minor bleeding (n = 1), wound infection (n = 1), incisional hernia (n = 1), diarrhea (n = 1), dehydration (n = 1). The 30-day readmission rate was 9.5 percent (n = 4). Two patients had reoperation within 30 days for small-bowel obstruction and a wound infection. CONCLUSIONS: Ileostomy closure patients managed with postoperative care pathways can have a short hospital stay with acceptable morbidity and readmission rates.

Clinical results of intraoperative radiation therapy for patients with locally recurrent and advanced tumors having colorectal involvement.

BACKGROUND: Intraoperative radiation therapy (IORT) may be useful in the treatment of patients who have a locally advanced primary and recurrent abdominopelvic neoplasm with colorectal involvement. METHODS: A retrospective review of colorectal cancer patients treated since 1999 with IORT using the Mobetron device. RESULTS: Forty patients underwent colectomy or proctectomy with IORT. All patients had evidence of local extension to contiguous structures and based on preoperative staging were deemed by the operating surgeon as being likely to have incomplete resection. IORT was selected as an alternative to sacrectomy or exenteration for an expected close margin in 10 patients. Mean survival was 35 +/- 26 months, and 1 patient had local recurrence. CONCLUSIONS: The introduction of IORT has allowed a selective treatment approach to locally advanced primary and recurrent neoplasms, which traditionally would have been deemed unresectable. Using IORT, extended resections may be avoided in selected high-risk patients with low risk of local recurrence and minimal morbidity.