Clinical applications of pelvic floor imaging: opinion statement endorsed by the society of abdominal radiology (SAR), American Urological Association (AUA), and American Urogynecologic Society (AUGS).

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

Overuse and Limited Benefit of Chemotherapy for Stage II Colon Cancer in Young Patients.

BACKGROUND: Few studies have confirmed a benefit for adjuvant chemotherapy (aCTX) in stage II colon cancer. We used the National Cancer Database to explore the use and efficacy of aCTX in patients with both normal-risk (NR) and high-risk (HR) young stage II colon cancer. PATIENTS AND METHODS: We identified patients with stage II colon cancer who underwent colectomy between 2010 and 2015. HR patients included at least: lymphovascular or perineural invasion, < 12 lymph nodes, poor/un-differentiation, T4, or positive margins. Rates of aCTX by age and risk were calculated, and adjusted factors associated with aCTX were identified. Overall survival was estimated using the Kaplan-Meier method and Cox multivariable analyses for patients < 50 years. RESULTS: Among the 81,066 stage II patients who underwent colectomy, 6093 (7.5%) were < 50 years old. Of these, 2669 patients were HR. Thirty percent of NR and almost 60% of HR patients < 50 years received aCTX, compared with 8% and 23% of patients > 50 years (P < .001). In NR patients < 50 years, 35.3% with microsatellite-stable tumors and 18% with microsatellite unstable tumors received aCTX (P < .001), whereas 63.6% and 43.2%, respectively, of HR patients did (P < .001). The most significant multivariable predictors of aCTX were risk status and age. On univariate analysis, there was no survival benefit associated with aCTX in patients < 50 years. Multivariate analysis failed to demonstrate a survival benefit for aCTX for either group (HR, 0.97; P = .84; NR, 0.1.03; P = .90). CONCLUSION: Young patients with HR and NR colon cancer received aCXT more frequently than older patients with no demonstrable survival benefit. This bears further evaluation to avoid the real risks of over-treatment in this increasing population.

Ostomy-Related Complications.

Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the frequency with which intestinal stomas are created, stoma-related complications remain common and are associated with significant morbidity as well as cost. Some of the most prevalent complications of stoma formation which will be detailed in this article include peristomal skin complications, retraction, stomal necrosis, stomal stenosis, prolapse, bleeding, dehydration from high ostomy output, and parastomal hernia. The authors will review these common complications, detail means to avoid or prevent them, and outline recommendations for management.

Elective colon resection without curative intent in stage IV colon cancer.

BACKGROUND: Evidence suggests that elective primary colon resection (ePCR) in patients with asymptomatic colon tumors and unresectable metastases is not required and may expose patients to unnecessary operative risk. METHODS: Stage IV colon cancer patients with liver metastases from 2000 to 2011 were identified with SEER-Medicare data. Liver-based therapy or urgent/emergent colectomies were excluded. Chemotherapy alone was compared to ePCR ±â€¯chemotherapy. Univariate and multivariate analyses were used to identify predictors of ePCR. Multivariate Cox regression compared survival. RESULTS: 5139 patients were identified. The ePCR rate decreased over time; 84% underwent ePCR in 2000, compared to 52% in 2011 (p < 0.001). In multivariate analysis, older patients were more likely to undergo ePCR, as were patients from rural areas (OR 1.65, p < 0.001). The odds of PCR in high poverty areas (>10%) were almost 25% higher than those in low poverty areas (OR 1.23, p = 0.03). African-Americana were less likely to undergo PCR than Caucasians (OR 0.76, p = 0.01). In multivariate survival analysis, PCR was associated with a significant survival benefit (HR 0.59, p < 0.001). CONCLUSIONS: Although ePCR is not recommended with unresectable metastases and the rate has decreased significantly, over 50% of patients with untreated hepatic metastases underwent ePCR in 2011. Disparities exist in use of ePCR that are likely multifactorial and deserve further study.

Anal and Perineal Injuries.

With increased use of explosive devices in warfare, anal trauma is often seen coupled with more complex pelviperineal injury. While the associated mortality is high, casualties that survive are often left with disabling fecal incontinence from damage to the anosphincteric complex. After resolution of the acute insult, the initial evaluation mandates a thorough physical exam, including endoscopic evaluation with rigid proctoscopy and flexible sigmoidoscopy, as well as adjunctive testing, specifically anal manometry and endoanal ultrasound. First-line therapy favors bulking agents and antidiarrheals, in conjunction with biofeedback, due to a minimal risk profile. Surgical options range from direct sphincter repairs to complex anosphincteric reconstruction with widely variable results. Most recently, burgeoning therapies in the treatment of fecal incontinence, including sacral nerve stimulation and magnetic anal sphincters, offer excellent alternatives with promising long-term outcomes. In summation, the goal of all interventions is the re-establishment of bowel continence, but, in its absence, permanent fecal diversion for devastating fecal incontinence is a reasonable option with excellent patient satisfaction scores.

Transanal Minimally Invasive Surgery.

Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.

Colorectal Specialization Increases Lymph Node Yield: Evidence from a National Database.

BACKGROUND: Current guidelines recommend the evaluation of at least 12 lymph nodes (LNs) in the pathologic specimen following surgery for colorectal cancer (CRC). We sought to examine the role of colorectal specialization on nodal identification. METHODS: We conducted a retrospective cohort study using SEER-Medicare data to examine the association between colorectal specialization and LN identification following surgery for colon and rectal adenocarcinoma between 2001 and 2009. Our dataset included patients >65 years who underwent surgical resection for CRC. We excluded patients with rectal cancer who had received neoadjuvant therapy. The primary outcome measure was the number of LNs identified in the pathologic specimen following surgery for CRC. Multivariate analysis was used to identify the association between surgical specialization and LN identification in the pathologic specimen. RESULTS: In multivariate analysis, odds of an adequate lymphadenectomy following surgery with a colorectal specialist were 1.32 and 1.41 times greater for colon and rectal cancer, respectively, than following surgery by a general surgeon (p < 0.001). These odds increased to 1.36 and 1.58, respectively, when analysis was limited to board-certified colorectal surgeons. Hospital factors associated with ≥12 LNs identified included high-volume CRC surgery (colon OR 1.84, p < 0.001; rectal OR 1.78, p < 0.001) and NCI-designated Cancer Centers (colon OR 1.75, p < 0.001; rectal OR 1.64; p = 0.007). CONCLUSIONS: Colorectal specialization and, in particular, board-certification in colorectal surgery, is significantly associated with increased LN identification following surgery for colon and rectal adenocarcinoma since the adoption of the 12-LN guideline in 2001.

Current surgical strategies to treat fecal incontinence.

Fecal incontinence is a devastating condition, vastly under-reported, and may affect up to 18% of the population. While conservative management may be efficacious in a large portion of patients, those who are refractory will likely benefit from appropriate surgical intervention. There are a wide variety of surgical approaches to fecal incontinence management, and knowledge and experience are crucial to choosing the appropriate procedure and maximizing functional outcome while minimizing risk. In this article, we provide a comprehensive description of surgical options for fecal incontinence to help the clinician identify an appropriate intervention.

Social media is a necessary component of surgery practice.

Social media is a necessary component of the practice of surgery. Each surgeon must embrace the power and potential of social media and serve as a guide or content expert for patients and other health care providers to facilitate and share responsible use of the various media available. Social media facilitates rapid communication of information not only across providers but also between patients and providers. The power of social media has the potential to improve consultation and collaboration, facilitate patient education, and expand research efforts; moreover, by harnessing its potential, the appropriate use of many of the avenues of social media also can be used to disseminate campaigns to increase disease awareness and communicate new research findings and best-practice guidelines. Because its reach is so broad within as well as outside the censorship of medical experts, professional oversight and engagement is required to maximize responsible use. Staying consistent with our history of surgery, rich in innovation and technologic advancement, surgeons must get to the front of this evolving field and direct the path of social media as it applies to the practice of surgery rather than take a passive role.

Management of malignant colon polyps: current status and controversies.

Colon cancer remains a significant clinical problem worldwide and in the United States it is the third most common cancer diagnosed in men and women. It is generally accepted that most malignant neoplasms of the colon arise from precursor adenomatous polyps. This stepwise progression of normal epithelium to carcinoma, often with intervening dysplasia, occurs as a result of multiple sequential, genetic mutations-some are inherited while others are acquired. Malignant polyps are defined by the presence of cancer cells invading through the muscularis mucosa into the underlying submucosa (T1). They can appear benign endoscopically but the presence of malignant invasion histologically poses a difficult and often controversial clinical scenario. Emphasis should be initially focused on the endoscopic assessment of these lesions. Suitable polyps should be resected en-bloc, if possible, to facilitate thorough evaluation by pathology. In these cases, proper attention must be given to the risks of residual cancer in the bowel wall or in the surrounding lymph nodes. If resection is not feasible endoscopically, then these patients should be referred for surgical resection. This review will discuss the important prognostic features of malignant polyps that will most profoundly affect this risk profile. Additionally, we will discuss effective strategies for their overall management.

Parastomal hernia repair and reinforcement: the role of biologic and synthetic materials.

Parastomal hernia is a prevalent problem and treatment can pose difficulties due to significant rates of recurrence and morbidities of the repair. The current standard of care is to perform parastomal hernia repair with mesh whenever possible. There exist multiple options for mesh reinforcement (biologic and synthetic) as well as surgical techniques, to include type of repair (keyhole and Sugarbaker) and position of mesh placement (onlay, sublay, or intraperitoneal). The sublay and intraperitoneal positions have been shown to be superior with a lower incidence of recurrence. This procedure may be performed open or laparoscopically, both having similar recurrence and morbidity results. Prophylactic mesh placement at the time of stoma formation has been shown to significantly decrease the rates of parastomal hernia formation.

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.

The impact of pregnancy on surgical Crohn disease: an analysis of the Nationwide Inpatient Sample.

BACKGROUND: The impact of pregnancy on the course of Crohn disease is largely unknown. Retrospective surveys have suggested a variable effect, but there are limited population-based clinical data. We hypothesized pregnant women with Crohn disease will have similar rates of surgical disease as a nonpregnant Crohn disease cohort. MATERIAL AND METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify female Crohn patients from all patients admitted using the Nationwide Inpatient Sample (1998-2009). Women were stratified as either pregnant or nonpregnant. We defined Crohn-related surgical disease as peritonitis, gastrointestinal hemorrhage, intra-abdominal abscess, toxic colitis, anorectal suppuration, intestinal-intestinal fistulas, intestinal-genitourinary fistulas, obstruction and/or stricture, or perforation (excluding appendicitis). RESULTS: Of the 92,335 women admitted with a primary Crohn-related diagnosis, 265 (0.3%) were pregnant. Pregnant patients were younger (29 versus 44 y; P<0.001) and had lower rates of tobacco use (6% versus 13%; P<0.001). Pregnant women with Crohn disease had higher rates of intestinal-genitourinary fistulas (23.4% versus 3.0%; P<0.001), anorectal suppuration (21.1% versus 4.1%; P<0.001), and overall surgical disease (59.6% versus 39.2%; P<0.001). On multivariate logistic regression analysis controlling for malnutrition, smoking, age, and prednisone use, pregnancy was independently associated with higher rates of anorectal suppuration (odds ratio [OR], 5.2; 95% confidence interval [CI], 3.8-7.0; P<0.001), intestinal-genitourinary fistulas (OR, 10.4; 95% CI, 7.8-13.8; P<0.001), and overall surgical disease (OR, 2.9; 95% CI, 2.3-3.7; P<0.001). CONCLUSIONS: Pregnancy in women with Crohn disease is a significant risk factor for Crohn-related surgical disease, in particular, anorectal suppuration and intestinal-genitourinary fistulas.

Crohn's disease and pregnancy: the impact of perianal disease on delivery methods and complications.

BACKGROUND: The optimal delivery method in patients with Crohn's disease is unknown, and there is no large-scale evidence on which to base decisions. OBJECTIVE: The aim of this study was to compare delivery methods and outcomes in patients with and without Crohn's disease. DESIGN AND PATIENTS: The Nationwide Inpatient Sample and International Classification of Diseases, Ninth Revision codes were used to identify childbirth deliveries. Patients were stratified by the presence or absence of Crohn's disease and perianal disease (anorectal fistula or abscess, rectovaginal fistula, anal fissure, and anal stenosis). SETTINGS: A large population-cohort database was used for the analysis. MAIN OUTCOME MEASURES: The primary outcomes measured were cesarean delivery and perineal lacerations. RESULTS: Of 6,794,787 pregnant women who delivered, 2882 had a diagnosis of Crohn's disease. Rates of cesarean delivery were higher in patients who had Crohn's disease with (83.1%) and without (42.8%) perianal disease in comparison with patients who did not have Crohn's disease with (38.9%) and without (25.6%) perianal disease (p < 0.001). Rates of 4th degree perineal lacerations were similar between patients who had or did not have Crohn's disease without perianal disease (1.4% vs 1.3%), but these rates increased significantly in patients with perianal disease (12.3%, p < 0.001). On multivariate analysis, perianal disease (OR, 10.9; 95% CI, 8.3-4.1; p < 0.001) and smoking (OR, 1.6; 95% CI, 1.5-1.7; p < 0.001) were independently associated with higher rates of 4th degree laceration. Crohn's disease was not independently associated with 4th degree laceration. LIMITATIONS: This was a retrospective study with the inherent limitations of large databases. CONCLUSIONS: Patients with Crohn's disease have higher rates of cesarean delivery. Perianal disease predicts severe perineal laceration independent of the presence of Crohn's disease. In the absence of perianal disease, the method of delivery in women with Crohn's disease should be predicated on obstetric indication.

Surgical management of fecal incontinence.

The surgical approach to treating fecal incontinence is complex. After optimal medical management has failed, surgery remains the best option for restoring function. Patient factors, such as prior surgery, anatomic derangements, and degree of incontinence, help inform the astute surgeon regarding the most appropriate option. Many varied approaches to surgical management are available, ranging from more conservative approaches, such as anal canal bulking agents and neuromodulation, to more aggressive approaches, including sphincter repair, anal cerclage techniques, and muscle transposition. Efficacy and morbidity of these approaches also range widely, and this article presents the data and operative considerations for these approaches.

Surgical treatment of anorectal crohn disease.

Crohn disease involves the perineum and rectum in approximately one-third of patients. Symptoms can range from mild, including skin tags and hemorrhoids, to unremitting and severe, requiring a proctectomy in a small, but significant, portion. Fistula-in-ano and perineal sepsis are the most frequent manifestation seen on presentation. Careful diagnosis, including magnetic resonance imaging or endorectal ultrasound with examination under anesthesia and aggressive medical management, usually with a tumor necrosis factor-alpha, is critical to success. Several options for definitive surgical repair are discussed, including fistulotomy, fibrin glue, anal fistula plug, endorectal advancement flap, and ligation of intersphincteric fistula tract procedure. All suffer from decreased efficacy in patients with Crohn disease. In the presence of active proctitis or perineal disease, no surgical therapy other than drainage of abscesses and loose seton placement is recommended, as iatrogenic injury and poor wound healing are common in that scenario.