Routine pathologic evaluation of circular stapler anastomotic rings is not useful after resection for colorectal cancer: retrospective study and systematic review with meta-analysis.

BACKGROUND: Circular staplers are commonly used for reconstruction after radical resection for colorectal cancer. Pathological analysis of the anastomotic rings is common practice, although the benefits are unclear. The purpose of this study was to evaluate the usefulness of routine histopathological analysis of anastomotic rings in an original series and in a systematic review of the literature. METHOD: The retrospective study was performed at two university-associated academic hospitals in Winnipeg, Canada, including patients investigated for colorectal cancers (within 30 cm of the anal verge) who underwent resection between 2007 and 2020. The systematic review involved Ovid MEDLINE, Embase, Scopus, and Web of Science databases, selecting for adult human studies involving analysis of anastomotic rings in elective colorectal cancer resections. The main outcome measure was the proportion of patients with cancer in the anastomotic ring specimens. The frequency of benign pathology findings and changes to patient management were also examined. RESULTS: Out of 673 eligible patients, 487 were included in the retrospective analysis. No patients had cancer within the anastomotic ring specimens. Twenty-five patients (5.1 per cent) had benign pathological findings within the anastomotic ring specimens, and patient management was never affected. In the systematic review, 27 articles were included in the final analysis out of 5848 records reviewed. The rate of cancer within anastomotic ring specimens was 0.34 per cent, and the rate of change in patient management was 0.19 per cent. CONCLUSION: The likelihood of finding cancer within anastomotic rings is rare and their histopathological examination seldom changes patient management.

Cost Analysis of Laparoscopic Low Anterior Resection vs. Transanal Endoscopic Microsurgery for Rectal Neoplasms.

Despite the increasing application of transanal endoscopic microsurgery (TEM) for rectal lesions, the cost of the equipment may play a role in a hospital's hesitancy to invest in the platform. This study compares the cost of TEM to laparoscopic low anterior resection (LAR). Patients who underwent laparoscopic LAR (n = 24) for rectal neoplasm between 2006 and 2014 were case-matched based on sex, age, comorbidities, lesion size and location to patients who underwent TEM at a busy secondary care urban hospital. Procedure-related costs and costs associated with readmissions for complications and related subsequent surgeries in the first 3 years were calculated. There were 42 hospital admissions for 24 LAR patients, totalling 326 hospital days. For 24 TEM patients, there were 25 hospital admissions, totalling 56 hospital days. Subsequent operations for LAR patients included 2 washout and diverting ileostomies (8%), 2 adhesionolysis (8%), 4 ventral hernia repairs (16%) and 11 ileostomy reversals (46%). In the TEM group, there was one operation for recurrence (4%). The mean cost of LAR, including all related hospital costs in the subsequent 3 years, was CAD 14,851 (95% CI: CAD 10,124-19,579). The mean cost of TEM was CAD 2449 (95% CI: CAD 2133-2767; p < 0.0001), with a savings of CAD 12,402 per patient. TEM for rectal neoplasm is associated with significantly lower hospital costs, which far outweigh the costs of acquiring and maintaining the technology.

The Association Between Wait Times for Colorectal Cancer Treatment and Health Care Costs: A Population-Based Analysis.

BACKGROUND: Health care costs and wait times for colorectal cancer treatment are increasing in Canada, but the association between the 2 remains unclear. OBJECTIVE: This study aimed to determine the association between wait times and health care costs and utilization. DESIGN: This is a population-based retrospective cohort study. SETTING: This study was conducted in Manitoba, Canada. PATIENTS: Patients diagnosed with colorectal cancer between 2004 and 2014 were sorted and ranked into quintiles based on the time from index contact for a colorectal cancer-related symptom to first treatment. MAIN OUTCOME MEASURES: The primary outcome is risk-adjusted health care costs, and the secondary outcomes include health care utilization and overall mortality. RESULTS: We included a total of 6936 patients. Total wait times ranged between 0 and 762 days. In comparison with very short wait times, longer wait times were associated with significantly increased costs (short: mean cost ratio 1.21; 95% CI, 1.10-1.32; moderate: mean cost ratio 1.30; 95% CI, 1.19-1.43; long: mean cost ratio 1.48; 95% CI, 1.33-1.64; and very long: mean cost ratio 1.39; 95% CI, 1.26-1.54). Compared with very short wait times, longer wait times were associated with significantly lower risk of mortality (short: HR, 0.78; 95% CI, 0.71-0.86; moderate: HR, 0.72; 95% CI, 0.65-0.80; long: HR, 0.73; 95% CI, 0.66-0.82; very long: HR, 0.76; 95% CI, 0.68-0.85). The median number of pretreatment radiological and endoscopic investigations and surgeon clinic visits increased over the study period across all wait time categories. LIMITATIONS: This is a nonrandomized, retrospective cohort study with potentially limited generalizability. CONCLUSION: Patients with very short and short wait times are likely those diagnosed with life-threatening complications of colorectal cancer. Outside this window, patients with longer wait times experience increased health care costs and utilization with similar overall mortality. Improved care coordination and patient navigation may help contain the increasing wait times and associated increasing health care costs and utilization. See Video Abstract at http://links.lww.com/DCR/B81. ASOCIACIÓN ENTRE LOS TIEMPOS DE ESPERA PARA EL TRATAMIENTO DE UN CÁNCER COLORRECTAL Y LOS COSTOS DE ATENCIÓN MÉDICA: UN ANÁLISIS DE POBLACIÓN: los costos de atención médica y los tiempos de espera para el tratamiento del cáncer colorrectal están aumentando en Canadá, pero la asociación entre los dos sigue sin estar clara.determinar la asociación entre los tiempos de espera y los costos y la utilización de la atención médicaun estudio de cohorte retrospectivo basado en la población.Manitoba, Canadálos pacientes diagnosticados con cáncer colorrectal entre 2004-2014 se clasificaron y sub-clasificaron en quintiles según el tiempo desde el primer contacto índice de síntomas relacionados con cáncer colorrectal hasta el primer tratamiento.El resultado primario son los costos de atención médica ajustados al riesgo, y los resultados secundarios incluyen la utilización de la atención médica y la mortalidad general.Incluimos un total de 6,936 pacientes. Los tiempos de espera totales oscilaron entre 0-762 días. En comparación con los tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con costos significativamente mayores (Corto: relación de costo promedio 1.21, intervalo de confianza del 95% 1.10-1.32; Moderado: relación de costo promedio 1.30, intervalo de confianza del 95% 1.19-1.43; Largo: media relación de costo 1.48, intervalo de confianza del 95% 1.33-1.64; Muy largo: relación de costo promedio 1.39, intervalo de confianza del 95% 1.26-1.54). En comparación con tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con un riesgo de mortalidad significativamente menor (Corto: razón de riesgo 0.78, intervalo de confianza del 95% 0.71-0.86; Moderado: razón de riesgo 0.72, intervalo de confianza del 95% 0.65-0.80; Largo: peligro cociente 0.73, intervalo de confianza del 95% 0.66-0.82; Muy largo: cociente de riesgos 0.76, intervalo de confianza del 95% 0.68-0.85). La mediana del número de investigaciones radiológicas y endoscópicas previas al tratamiento y las visitas al cirujano aumentaron durante el período de estudio en todas las categorías de tiempo de espera.estudio de cohortes retrospectivo, no aleatorio con generalización potencialmente limitadalos pacientes con tiempos de espera « muy cortos ¼ y « cortos ¼ son probablemente aquellos diagnosticados con complicaciones potencialmente mortales del cáncer colorrectal. Fuera de esta ventana, los pacientes con tiempos de espera más largos experimentan mayores costos de atención médica y utilización con una mortalidad general similar. La coordinación mejorada de la atención y la navegación del paciente pueden ayudar a contener el aumento de los tiempos de espera y el aumento de los costos y la utilización de la atención médica. Consulte Video Resumen en http://links.lww.com/DCR/B81. (Traducción-Dr. Edgar Xavier Delgadillo).

Synoptic operative reports enhance documentation of best practices for rectal cancer.

BACKGROUND: Implementation of best practices surgical checklists improves patient safety and outcomes. However, documenting performance of these practices can be challenging. The American Society of Colon and Rectal Surgeons developed a Best Practices for Rectal Cancer Checklist (RCC) to standardize and improve the quality of rectal cancer surgery. This study compared the degree to which synoptic (SR) and narrative (NR) operative reports document RCC items. METHODS: Two reviewers independently reviewed a cohort of prospectively collected SR for rectal cancer surgery and a case-matched historical cohort of NR. Reports were reviewed for documentation of performance of operative items on the RCC. Abstraction time and inter-rater agreement were also measured. RESULTS: SR scored significantly higher than NR on the overall checklist score (mean adjusted score ± standard deviation 12.4 ± 0.9 vs. 5.7 ± 1.9, maximum possible score 18, P < 0.001). Reviewers abstracted data significantly faster from SR. Inter-rater agreement between reviewers was high for both types of reports. CONCLUSIONS: SR were associated with reliable and more complete and reliable documentation of items on the RCC. Use of an SR system standardizes operative reporting, providing the opportunity to enhance checklist compliance, and enable timely feedback to improve surgical outcomes for rectal cancer patients.

Is obesity associated with advanced stage or grade of colon cancer?

Population-based studies from Europe have suggested that obesity is associated with more advanced stage colorectal cancer on presentation. Obesity is an even more prevalent issue in North America, but comparable data on associations with cancer are lacking. We reviewed the cases of 672 patients with colon cancer diagnosed between 2004 and 2008 in the province of Manitoba who underwent surgical resection at a Winnipeg Regional Health Authority­affiliated hospital. We tested if obesity was associated with more advanced cancer stage or grade. On multivariate analysis, after adjusting for age, sex,tumour location and socioeconomic status, we were unable to show any significant associations between body mass index of 30 or more and advanced stage or grade cancer on presentation. The reasons for the lack of association are likely multifactorial, including the pathophysiology of the disease and process factors, such as screening habits and colonoscopic diagnostic success rates in obese patients.

The location of surgical care for rural patients with rectal cancer: patterns of treatment and patient perspectives.

BACKGROUND: Where cancer patients receive surgical care has implications on policy and planning and on patients' satisfaction and outcomes. We conducted a population- based analysis of where rectal cancer patients undergo surgery and a qualitative analysis of rectal cancer patients' perspectives on location of surgical care. METHODS: We reviewed Manitoba Cancer Registry data on patients with colorectal cancer (CRC) diagnosed between 2004 and 2006. We interviewed rural patients with rectal cancer regarding their preferences and the factors they considered when deciding on treatment location. Interview data were analyzed using a grounded theory approach. RESULTS: From 2004 to 2006, 2086 patients received diagnoses of CRC in Manitoba (colon: 1578, rectal: 508). Among rural patients (n = 907), those with rectal cancer were more likely to undergo surgery at an urban centre than those with colon cancer (46.5% v. 28.8%, p < 0.001). Twenty rural patients with rectal cancer participated in interviews. We identified 3 major themes from the interview data: the decision-maker, treatment factors and personal factors. Participants described varying input into referral decisions, and often they did not perceive a choice regarding treatment location. Treatment factors, including surgeon factors and hospital factors, were important when considering treatment location. Personal factors, including travel, support, accommodation, finances and employment, also affected participants' treatment experiences. CONCLUSION: A substantial proportion of rural patients with rectal cancer undergo surgery at urban centres. The reasons are complex and only partly related to patient choice. Further studies are required to better understand cancer system access in geographically dispersed populations and to support cancer patients through the decision-making and treatment processes.

CONTEXTE: Le lieu où les patients atteints du cancer subissent une intervention chirurgicale a des répercussions sur les politiques et la planification, et sur la satisfaction du patient et ses résultats. Nous avons étudié dans une population le lieu où des patients atteints de cancer du rectum subissent leur chirurgie et effectué une analyse qualitative des points de vue exprimés par les patients au sujet du lieu où les soins chirurgicaux sont dispensés. MÉTHODES: Nous avons consulté le Registre du cancer du Manitoba pour trouver des données sur des patients atteints de cancer colorectal diagnostiqué entre 2004 et 2006. Nous avons interviewé des patients de régions rurales atteints de cancer du rectum pour connaître leurs préférences et les facteurs dont ils avaient tenu compte en choisissant le lieu où ils allaient être traités. Nous avons analysé les données recueillies à l'aide d'une méthode théorique fondées sur les faits. RÉSULTATS: Entre 2004 et 2006, au Manitoba, 2086 patients ont reçu un diagnostic de cancer colorectal (cancer du côlon : 1578; cancer du rectum : 508). Parmi les patients qui vivaient en milieu rural (n = 907), ceux atteints d'un cancer du rectum avaient plus tendance à subir leur chirurgie dans un établissement urbain que ceux atteints de cancer du côlon (46,5 % c. 28,8 %, p < 0,001). Vingt patients de milieu rural atteitns de cancer du rectum ont participé aux entrevues. Trois principaux éléments se dégagent des données recueillies : le décideur, des facteurs reliés au traitement et des facteurs d'ordre personnel. Les participants ont décrit diverses contributions qu'ils ont apportées à la décision relative à la référence de leur cas et dit que souvent, ils n'ont pas senti qu'un choix de lieux de traitement leur était offert. Les facteurs liés au traitement lui-même, y compris ceux liés au chirurgien et à l'hôpital, ont été importants dans le choix du lieu de traitement. Les facteurs d'ordre personnel, dont le déplacement, le soutien, l'hébergement, la situation financière et l'emploi ont aussi influé sur l'expérience thérapeutique des participants. CONCLUSION: Une proportion considérable de patients atteints du cancer du rectum et vivant en milieu rural subissent leur chirurgie dans des établissements urbains. Les raisons sont complexes et ne sont qu'en partie reliées au choix du patient. Il faudrait mener d'autres études pour mieux comprendre l'accès aux services offerts aux personnes atteintes de cancer dans les populations géographiquement dispersées et pour les appuyer dans le processus de prise de décision et de traitement.

Documentation of quality of care data for colon cancer surgery: comparison of synoptic and dictated operative reports.

BACKGROUND: Operative reports are a source of clinical data that can, for quality assurance purposes, be used to document the performance of processes that affect the care of surgical patients. We assessed the degree to which synoptic reports document operative quality indicators for colon cancer surgery. METHODS: Two reviewers independently reviewed 80 prospectively collected synoptic colon cancer operative reports and a case-matched historical cohort of 80 dictated reports. Reviewers rated how well reports documented performance of quality of care indicators using two checklists of previously validated, colon cancer-specific quality measures. Interrater agreement and time to extract data were also recorded. RESULTS: Synoptic reports had significantly higher overall scores on the quality indictors in comparison to dictated reports for both checklist 1 [mean adjusted score ± standard deviation 18.6 ± 1.3 vs. 9.2 ± 3.6, p < 0.01 (maximum score 38)] and checklist 2 [2.0 ± 0.3 vs. 1.3 ± 1.1, p < 0.01 (maximum score 3)]. Interrater agreement was significantly higher between synoptic reports for both checklists (data not shown). Data were extracted significantly more quickly from synoptic reports than dictated reports [mean time (minutes:seconds) ± standard deviation 2:32 ± 0:44 vs. 4:01 ± 1:14, p < 0.01]. CONCLUSIONS: Synoptic reports were associated with more complete documentation of quality indicators for colon cancer resection compared to dictated reports. Although synoptic reports may improve the documentation of quality of care data, further refinement may help to better document performance of quality measures and improve reporting standards.

Geographical disparities of rectal cancer local recurrence and outcomes: a population-based analysis.

BACKGROUND: Challenges exist in providing high-quality cancer treatments to populations spread over large geographical areas. Local recurrence of rectal cancer is a complicated clinical problem associated with high morbidity and mortality. OBJECTIVES: objectives of this study were to evaluate population-based rates and predictors of local recurrence of rectal cancer in the Province of Manitoba, Canada, with emphasis on the effects of geography. DESIGN: : This was a population-based retrospective analysis. Administrative data from the Manitoba Cancer Registry and individual patient charts were reviewed. SETTINGS: Patients with stages I to III rectal cancer who underwent surgery with curative intent in Manitoba between 2004 and 2006 were included. MAIN OUTCOME MEASURES: The primary outcome was the development of local recurrence after surgical resection. RESULTS: Three hundred seventy patients with a mean age of 67 years were identified. The 5-year local recurrence rate was 17.4%. In multivariate analysis, relative to Winnipeg residents, rural residents, regardless of where they underwent surgery, had an increased risk of local recurrence (HR, 3.47; 95% CI, 1.74-6.92 for surgery in Winnipeg; HR, 2.98; 95% CI, 1.59-5.57 for surgery in rural Manitoba). The absence of both neoadjuvant radiotherapy and adjuvant chemotherapy was associated with a higher risk of local recurrence. Higher risk of mortality was noted for rural patients (HR, 1.90; 95% CI, 1.24-2.89) and for those who developed local recurrence (HR, 2.01; 95% CI, 1.27-3.19). CONCLUSION: Local recurrence rates for rectal cancer are high in Manitoba. Geography is an important variable, because rural status is associated with higher local recurrence rates and decreased survival. The use of neoadjuvant radiotherapy was an important predictor of lower local recurrence rates. Further initiatives are imperative to identify why rural patients experience differences in outcomes in Manitoba.

Effect of an acute care surgical service on the timeliness of care.

BACKGROUND: In the spring of 2008, St. Boniface General Hospital in Winnipeg, Man., created an acute care surgical service (ACSS) designed to improve care for emergent, nontrauma surgical patients. We sought to assess the effect of the ACSS on patient care timeliness. METHODS: We retrospectively examined the time intervals in care for patients admitted with acute appendicitis, acute cholecystitis and small bowel obstruction in 3 study periods: pre-ACSS, newly formed ACSS and established ACSS. RESULTS: There was a 2-fold increase in patient volume after the ACSS was created. Patient characteristics were similar in all 3 groups. Time from triage to surgical consultation was also similar. The ACSS significantly reduced the duration of the surgical consultation (1 h 43 min in period 1 v. 62 min in period 2 and 49 min in period 3, p = 0.029). Time from admission to operation was similar despite a significant increase in patient load after the ACSS was created. Total length of hospital stay was similar except in the subgroup analysis (appendicitis + cholecystitis only), where the length of stay was reduced after creation of the ACSS (2 d 15 h pre- v. 1 d 19 h post-ACSS, p = 0.009). Most operations occurred between 4 pm and midnight. CONCLUSION: With the implementation of an ACSS, the number of surgical patients assessed and treated doubled. Despite the increased volume, consultations were completed significantly faster, there was no significant difference in time to operation, and on subgroup analysis length of hospital stay was significantly faster.

CONTEXTE: Au printemps 2008, l'Hôpital général de Saint-Boniface, à Winnipeg, au Manitoba, s'est doté d'un service de chirurgie de courte durée (SCCD) dans le but d'améliorer les soins aux patients qui doivent subir une chirurgie urgente non d'origine traumatique. Nous avons voulu mesurer l'impact du SCCD sur la rapidité avec laquelle les patients ont eu accès aux soins requis. MÉTHODES: Nous avons examiné de manière rétrospective combien de temps les patients admis pour appendicite aiguë, cholécystite aiguë et obstruction du grêle ont attendu avant de recevoir leur traitement au cours de 3 périodes distinctes : avant la création du SCCD, au moment de son déploiement et depuis son établissement. RÉSULTANTS: On a noté que le volume de patients traités a doublé après la création du SCCD. Les caractéristiques des patients des 3 groupes étaient similaires. Les délais entre le triage et la consultation en chirurgie étaient également similaires. Le SCCD a significativement abrégé la durée de la consultation en chirurgie (soit de 1 h 43 minà la période 1 c. 62 min à la période 2 et 49 min à la période 3, p = 0,029). Le délai entre l'admission et l'intervention est resté similaire malgré l'augmentation significative du nombre de patients après la création du SCCD. La durée totale du séjour hospitalier est restée inchangée, sauf dans l'analyse des sous-groupes (appendicite + cholécystite seulement), selon laquelle la durée du séjour a diminué après la création du SCCD (2 j 15 h pré-SCCD c. 1 j 19 h après SCCD, p = 0,009). La plupart des interventions ont été effectuées entre 16 heures et minuit. CONCLUSIONS: Avec la mise en place d'un SCCD, le nombre de patients de chirurgie évalués et traités a doublé. Et malgré cet accroissement de volume, les consultations ont eu lieu significativement plus rapidement. On n'a noté aucune différence significative quant au délai précédant l'intervention et à l'analyse des sous-groupes, la durée des hospitalisations a été significativement plus brève.

Attending surgeon burnout and satisfaction with the establishment of a regional acute care surgical service.

BACKGROUND: Establishment of the Acute Care Surgical Service (ACSS) has dramatically changed the management of acute, nontrauma surgical patients in Winnipeg, Manitoba. Its formation was partially driven by increasing strain on surgeons and surgical services. We sought to determine surgeon level of burnout and satisfaction with the ACSS. METHODS: All Winnipeg ACSS surgeons were mailed surveys. Burnout was established using the Maslach Burnout Inventory Human Services Survey. Satisfaction was ascertained with a series of questions. RESULTS: We attained a response rate of 76%. Most surgeons were married men with children. A burnout level of 61% was determined. Although most surgeons felt the ACSS was a positive change in their careers, they felt that operating room accessibility and teaching opportunities were lacking. CONCLUSION: Although a high level of burnout exists among ACSS surgeons, most are satisfied with its establishment. Factors such as operating room accessibility and teaching opportunities must be addressed.

Evaluation of a regional acute care surgery service by residents in general surgery.

BACKGROUND: Acute care surgery (ACS) services dedicated to care of acute general surgery patients have been established in many tertiary centers across Canada. Little is known about the impact of this trend on postgraduate education. In this study we aimed to evaluate ACS through a cross-sectional survey of general surgery residents in Winnipeg, Manitoba. METHODS: General surgery residents at the University of Manitoba were asked to complete an anonymous survey. Basic demographic data were obtained. The educational value of ACS was assessed using 10 statements derived from the CanMEDS framework for training physicians. Resident burnout was measured using the Maslach Burnout Inventory, on emotional exhaustion, depersonalization, and personal accomplishment. RESULTS: The response rate was 70% (14/20). ACS was evaluated positively based on the CanMEDS roles by the following proportions of responders: surgical skills (79%), clinical knowledge (100%), communicator (100%), collaborator (100%), manager (86%), health advocate (100%), scholar (64%), and professional (93%). Fifty percent of responders had a high score on emotional exhaustion, 43% on depersonalization, and 0% on low sense of personal accomplishment. The overall burnout was 64%. CONCLUSIONS: ACS provides a comprehensive clinical experience based on the CanMEDS competencies. Despite an increased sense of personal accomplishment, residents experienced a high incidence of burnout, as demonstrated by high scores on emotional exhaustion and depersonalization of patients.

Equivalency of lymph node harvest in laparoscopic versus open colorectal cancer procedures: an early surgeon's perspective.

PURPOSE: To compare the number of lymph nodes harvested in laparoscopic versus open colorectal cancer surgery early in a surgeon's career. METHODS: We reviewed the data of 80 patients operated upon with a primary diagnosis of colorectal cancer between September 2006 and June 2008. All data were from a single fellowship trained colorectal surgeon. The effects of laparoscopic versus open surgery, and neoadjuvant radiation were examined to assess lymph node harvest. RESULTS: There was no statistically significant difference between the lymph nodes harvested during laparoscopic versus open surgery (17.4 vs 18.5; P=0.5920). The amount of lymph nodes harvested decreased with increasing American Society of Anesthesiology grade (22.4, 17.1, 19.2, 7.0 for American Society of Anesthesiology grade I, II, III, IV, respectively; P=0.0412) and with neoadjuvant radiotherapy (18.7 vs 13.2; P=0.0151). CONCLUSIONS: Laparoscopic colorectal cancer surgery results in the same number of lymph nodes being harvested as in open surgery.

Laparoscopic management of splenic cysts: marsupialization, cavity lining with surgicel and omentopexy to prevent recurrence.

INTRODUCTION: Open total splenectomy, once the treatment of choice for splenic cysts, has largely been replaced by laparoscopic, splenic preserving procedures. These techniques have resulted in reduced hospitalization times and rates of overwhelming postsplenectomy infection. We report 2 cases of laparoscopic management of large, symptomatic splenic cysts. METHODS: Two patients presented with symptomatic splenic cysts. The first was a simple cyst by history, the second a posttraumatic cyst. Both patients were treated by laparoscopic cyst marsupialization followed by lining the cavity with Surgicel (Ethicon, Somerville, NJ) and performance of an omentopexy. RESULTS: Both procedures were performed without complication. At 25 months, neither patient showed any evidence of symptomatic or radiologic recurrence. Pathology confirmed the preoperative diagnoses. CONCLUSIONS: Laparoscopic marsupialization of splenic cysts in combination with lining the cyst cavity with Surgicel and omentopexy is a safe, feasible, and efficacious method of management with excellent results at 25-month follow-up.

Hand-assisted laparoscopic total proctocolectomy and ileal pouch-anal anastomosis after liver transplant for primary sclerosing cholangitis.

Chronic ulcerative colitis (CUC) is associated with extraintestinal manifestations such as primary sclerosing cholangitis (PSC). The onset of PSC can precede the diagnosis of CUC, and require liver transplantation in some patients. Surgical management of CUC posttransplant has traditionally been open total proctocolectomy and ileal pouch-anal anastomosis. Herein, we present a case of a woman with a previous liver transplant for PSC who subsequently developed CUC with dysplasia, successfully treated with hand-assisted laparoscopic total proctocolectomy and ileal pouch-anal anastomosis. Hand-assisted laparoscopic surgery is an excellent option for patients with previous complex abdominal surgery. It can be performed safely and expediently, providing the benefits of reduced hospital stay and early return of bowel function.