Functional Outcomes After Transanal Total Mesorectal Excision (taTME) for Rectal Cancer: Results from the Phase II North American Multicenter Prospective Observational Trial.

OBJECTIVE: To investigate fecal incontinence and defecatory, urinary, and sexual functional outcomes after taTME. SUMMARY BACKGROUND DATA: Proctectomy for rectal cancer may result in alterations in defecatory, urinary, and sexual function that persist beyond 12 months. The recent multicenter Phase II taTME trial demonstrated the safety of taTME in patients with stage I-III tumors. METHODS: Prospectively registered self-reported questionnaires were collected from 100 taTME patients. Fecal continence (FIQL, Wexner), defecatory function (COREFO), urinary function (IPSS), and sexual function (FSFI-female, IIEF-male) were assessed preoperatively (PQ), 3-4 months post-ileostomy closure (FQ1), and 12-18 months post-taTME (FQ2). RESULTS: Among 83 patients who responded at all three time points, FIQL, Wexner, and COREFO significantly worsened post-ileostomy closure. Between FQ1 and FQ2, FIQL lifestyle and coping, Wexner, and COREFO incontinence, social impact, frequency, and need for medication significantly improved, while FIQL depression and embarrassment did not change. IPSS did not change relative to preoperative scores. For females, FSFI declined for desire, orgasm, and satisfaction between PQ and FQ1, and did not improve between FQ1 and FQ2. In males, IIEF declined with no change between FQ1 and FQ2. CONCLUSIONS: Although taTME resulted in initial decline in defecatory function and fecal continence, most functional domains improved by 12 months after ileostomy closure, without returning to preoperative status. Urinary function was preserved while sexual function declined without improvement by 18 months post-taTME. Our results address patient expectations and inform shared decision-making regarding taTME.

Oncologic outcomes following transanal total mesorectal excision: the United States experience.

AIM: The benefits and short-term outcomes of transanal total mesorectal excision (taTME) for rectal cancer have been demonstrated previously, but questions remain regarding the oncologic outcomes following this challenging procedure. The purpose of this study was to analyze the oncologic outcomes following taTME at high-volume centers in the USA. METHODS: This was a multicenter, retrospective observational study of 8 tertiary care centers. All consecutive taTME cases for primary rectal cancer performed between 2011 and 2020 were included. Clinical, histopathologic, and oncologic data were analyzed. Primary endpoints were rate of local recurrence, distal recurrence, 3-year disease recurrence, and 3-year overall survival. Secondary endpoints included perioperative complications and TME specimen quality. RESULTS: A total of 391 patients were included in the study. The median age was 57 years (IQR: 49, 66), 68% of patients were male, and the median BMI was 27.4 (IQR: 24.1, 31.0). TME specimen was complete or near complete in 94.5% of cases and the rates of positive circumferential radial margin and distal resection margin were 2.0% and 0.3%, respectively. Median follow-up time was 30.7 months as calculated using reverse-KM estimator (CI 28.1-33.8) and there were 9 cases (2.5%) of local recurrence not accounting for competing risk. The 3-year estimated rate of disease recurrence was 19% (CI 15-25%) and the 3-year estimated overall survival was 90% (CI 87-94%). CONCLUSION: This large multicenter study confirms the oncologic safety and perioperative benefits of taTME for rectal cancer when performed by experienced surgeons at experienced referral centers.

SafeHeal Colovac Colorectal Anastomosis Protection Device evaluation (SAFE-2) pivotal study: an international randomized controlled study to evaluate the safety and effectiveness of the Colovac Colorectal Anastomosis Protection Device.

AIM: Although proximal faecal diversion is standard of care to protect patients with high-risk colorectal anastomoses against septic complications of anastomotic leakage, it is associated with significant morbidity. The Colovac device (CD) is an intraluminal bypass device intended to avoid stoma creation in patients undergoing low anterior resection. A preliminary study (SAFE-1) completed in three European centres demonstrated 100% protection of colorectal anastomoses in 15 patients, as evidenced by the absence of faeces below the CD. This phase III trial (SAFE-2) aims to evaluate the safety and effectiveness of the CD in a larger cohort of patients undergoing curative rectal cancer resection. METHODS: SAFE-2 is a pivotal, multicentre, prospective, open-label, randomized, controlled trial. Patients will be randomized in a 1:1 ratio to either the CD arm or the diverting loop ileostomy arm, with a recruitment target of 342 patients. The co-primary endpoints are the occurrence of major postoperative complications within 12 months of index surgery and the effectiveness of the CD in reducing stoma creation rates. Data regarding quality of life and patient's acceptance and tolerance of the device will be collected. DISCUSSION: SAFE-2 is a multicentre randomized, control trial assessing the efficacy and the safety of the CD in protecting low colorectal anastomoses created during oncological resection relative to standard diverting loop ileostomy. TRIAL REGISTRATION: NCT05010850.

Racial disparities in survival of early onset colon cancer (Age<50): A matched NCDB analysis.

BACKGROUND: Early-onset colon cancer (EOCC) has increasing incidence and disproportionately affects African-Americans. This analysis aims to compare EOCC survival among Black and White patients after matching relevant socio-demographic factors and stage. METHODS: The 2004-2017 NCDB database was queried for Black and White patients, age<50, who underwent colectomy for adenocarcinoma. A one-to-one match on race was performed based on sociodemographic factors and disease stage (I-IV). Five-year survival differences were analyzed with Cox proportional hazards models. RESULTS: 5322 Black-White matched pairs were analyzed. Compared to White patients, Black patients averaged more days to surgery (19 â€‹± â€‹68 vs 16 days â€‹± â€‹32, p â€‹< â€‹0.001) and to chemotherapy (63 â€‹± â€‹8 vs. 57 â€‹± â€‹39, p â€‹< â€‹0.001). Black stage III patients were 20% less likely to receive chemotherapy (OR 0.8, 95% CI 0.7-0.9, p â€‹= â€‹0.0006), and had a 17% increased rate of death (HR 1.17, 95% CI 1.0-1.3, p â€‹= â€‹0.01) after adjusting for sex, comorbidity score, tumor location and chemotherapy. CONCLUSIONS: Black patients with stage 3 EOCC are less likely to receive chemotherapy and have worse survival. Further evaluation is warranted to identify potential factors driving these observed.

Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results.

BACKGROUND: Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765). METHODS: 100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications. RESULTS: Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003). CONCLUSION: When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.

Discordance in Total Mesorectal Excision Specimen Grading in a Prospective Phase 2 Multicenter Rectal Cancer Trial: Are We Overestimating the Quality of Our Resections?

OBJECTIVES: To report the results of a rigorous quality control (QC) process in the grading of total mesorectal excision (TME) specimens during a multicenter prospective phase 2 trial of transanal TME. BACKGROUND: Grading of TME specimens is based on the macroscopic assessment of the mesorectum and standardized through synoptic pathology reporting. TME grade is a strong predictor of outcomes with incomplete (IC) TME associated with increased rates of local recurrence relative to complete or near complete (NC) TME. Although TME grade serves as an endpoint in most rectal cancer trials, in protocols incorporating centralized review of TME specimens for quality assurance, discordance in grading and the management thereof has not been previously described. METHODS: A phase 2 prospective transanal TME trial was conducted from 2017 to 2022 across 11 North American centers with TME quality as the primary study endpoint. QC measures included (1) training of site pathologists in TME protocols, (2) blinded grading of de-identified TME specimen photographs by central pathologists, and (3) reconciliation of major discordance before trial reporting. Cohen Kappa statistic was used to assess agreement in grading. RESULTS: Overall agreement in grading of 100 TME specimens between site and central reviewer was rated as fair, (κ = 0.35; 95% CI: 0.10-0.61; P < 0.0001). Concordance was noted in 54%, with minor and major discordance in 32% and 14% of cases, respectively. Upon reconciliation, 13/14 (93%) major discordances were resolved. Pre versus postreconciliation rates of complete or NC and IC TME are 77%/16% and 7% versus 69%/21% and 10%. Reconciliation resulted in a major upgrade (IC-NC; N = 1) or major downgrade (NC/C-IC, N = 4) in 5 cases overall (5%). CONCLUSIONS: A 14% rate of major discordance was observed in TME grading between the site and central reviewers. The resolution resulted in a major change in final TME grade in 5% of cases, which suggests that reported rates or TME completeness are likely overestimated in trials. QC through a central review of TME photographs and reconciliation of major discordances is strongly recommended.

Assessing the Quality of Online Health Information and Trend Data for Colorectal Malignancies.

INTRODUCTION: Patients often refer to the internet to learn about different health conditions. This study aims to assess the landscape of online health information on malignant colorectal conditions, focusing on the popularity, quantity, and quality of internet resources pertaining to these conditions. This information can be used as a guide for surgeons to supplement patient information at the time of surgical evaluation and to help design optimal online health information. METHODS: The terms "colon cancer," "rectal cancer," "anal cancer," and "colorectal cancer" were searched using the Google search engine. The number of search results or "hits" obtained per search term was recorded and the first 50 websites for each search term were reviewed. Included websites did not have a password requirement, were in English, and were free. Quality assessments were performed using the DISCERN instrument, and mean DISCERN scores were compared using analysis of variance. The popularity of each search term was determined using Google Trends, which generates a relative search volume score. RESULTS: A total of 431 million hits were obtained for the term "colon cancer," 72.5 million for "rectal cancer," 244 million for "anal cancer," and 194 million for "colorectal cancer." Mean DISCERN scores for reviewed websites ranged between 39.7 and 40.6, and were thus within the "fair" category. There were no significant differences in mean DISCERN scores across search terms (P = 0.5). Colon cancer had the highest relative search volume score (61.8), followed by colorectal cancer (43.4/100), rectal cancer (42.5/100), and anal cancer (41.7/100). CONCLUSIONS: Although there is a large amount of online information on malignant colorectal conditions, the quality of the available information is inadequate. Clinician guidance to resources aimed at higher quality from guidance of the DISCERN tool may be of value for patient education.

Prospective Evaluation of a Tiered Opioid Prescribing Guideline for Inpatient Colorectal Operations.

OBJECTIVE: This study sought to prospectively validate an institutional prescribing guideline based on previously defined opioid consumption patterns following inpatient colorectal operations. BACKGROUND: In light of the opioid epidemic, reducing excess prescription quantities is key while still tailoring to patient needs. METHODS: This is a cohort study of elective colorectal operations (colectomies, proctectomies, and ostomy reversals) at a single tertiary care medical center. Opioid prescribing and consumption patterns [quantified as Equianalgesic 5 mg Oxycodone Pills (EOP)] were compared before and after adoption of a tiered opioid prescribing guideline. Tiers were divided based on opioid consumption in the 24 hours before discharge: Tier 1 (0 EOP), Tier 2 (0.1-3 EOP), and Tier 3 (>3 EOP). Our guideline recommended maximum prescriptions of 0 EOP for Tier 1, 12 EOP for Tier 2, and 30 EOP for Tier 3. Results: The study included 100 patients before and 101 after guideline adoption. Demographic and operative characteristics were similar between cohorts. Guideline adherence was 85%. Overall, there was a 41%reduction in mean prescription quantity and 53% reduction in excess pills per prescription. No change in opioid consumption or refill rates was observed. CONCLUSIONS: Adoption of a tiered opioid prescribing guideline significantly reduced opioid prescription quantity with no change in consumption or refill rates. Standardization of discharge prescriptions based on patient consumption in the 24 hours before discharge may be an important step toward minimizing excess prescribing.

Efficacy and satisfaction of asynchronous TeleHealth care compared to in-person visits following colorectal surgical resection.

BACKGROUND: The feasibility of remote visits following abdominal colorectal surgery has not been studied in relation to efficacy, patient satisfaction, and surgeon satisfaction. This study aims to assess reliability and satisfaction with a web-based questionnaire for post-operative visits following abdominal colorectal surgery. METHODS: This was a prospective single-arm cohort study at single-tertiary care center during admission for abdominal colorectal surgery. Using a web-based patient portal, patients completed a questionnaire 48 h prior to their scheduled in-person follow-up visits and submitted photographs of their incisions. Surgeons reviewed patient-entered data and responded within 24 h. Following the subsequent in-person visit, surgeons completed questionnaires to compare the accuracy of the web-based vs. in-person evaluations. Lastly, patients and surgeons completed separate satisfaction surveys after the in-person visits. RESULTS: A total of 33 patients were enrolled, of which 30 (90.9%) successfully completed the web questionnaire. Providers reported the online questionnaire to be concordant with the in-person visit in 90% of cases. Of the patients who completed the study, only half found the survey alone to be acceptable for follow-up. Patients spent significantly less time completing the online questionnaire (≤ 10 min) than in-person visits, including travel time (75 min, IQR 50-100). Only 12 patients (40%) uploaded photographs of their incisions. During in-person visits, management changes were employed in four patients (13.3%), of which 3 required treatment of superficial surgical site infections (10%). CONCLUSION: This asynchronous web-based visit format was acceptable to colorectal surgeons but was only embraced by half of patients, despite considerable time savings. While patients preferred in-person visits, there may be opportunities to expand TeleHealth acceptance that focus on patient selection and education. CLINICALTRIALS: gov: NCT05084131.

Postcolonoscopy Complications.

CASE SUMMARY: A 62-year-old woman presents for her first screening colonoscopy as recommended by her primary care physician after an initial health maintenance examination to establish care. A 1-cm sessile polyp was found in the cecum during the colonoscopy, which was resected using hot snare polypectomy. After appropriate postprocedure recovery, the patient was sent home and presented 12 hours later to the emergency department with severe abdominal pain.

S184: preoperative sarcopenia is associated with worse short-term outcomes following transanal total mesorectal excision (TaTME) for rectal cancer.

INTRODUCTION: Malnutrition and deconditioning impact postoperative morbidity and mortality. Computed tomography (CT) body composition variables are used as markers of nutritional status and sarcopenia. The objective of this study is to evaluate the impact of sarcopenia, using CT variables, on postoperative outcomes following transanal total mesorectal excision (TaTME) for rectal cancer. METHODS: This was an institutional retrospective cohort analysis of consecutive rectal cancer patients who underwent TaTME between April 2014 and May 2020. Psoas muscle index (PMI) was calculated from diagnostic CT scans. Based on previous studies, patients in the lowest PMI tertile by gender were considered sarcopenic. Fisher's exact and Mann-Whitney U test were used to compare categorical and continuous variables, respectively. Readmission rates and postoperative complications were compared between groups. Backward stepwise logistic regression was used to determine the association between sarcopenia and 30-day postoperative complications. RESULTS: 85 patients were analyzed, of which 63% were male, with a median age of 59 (IQR: 51-65), and median BMI of 28 (IQR: 24-32). Of the entire cohort, 34% (n = 29) were sarcopenic (median PMI 5.39 IQR: 4.49-6.71). No significant difference in baseline characteristics between sarcopenic and nonsarcopenic patients were observed. 55% of sarcopenic patients experienced a complication within 30 days compared to 24% of nonsarcopenic patients (p = 0.01). 41% of sarcopenic patients required hospital readmission within 30 days compared to 17% of their nonsarcopenic counterparts (p = 0.014). Sarcopenic patients also experienced significantly higher rates of post-operative small bowel obstruction (10% vs. 0%, p = 0.04). Multivariable analyses identified that sarcopenic patients have a fourfold increase in odds of experiencing a 30-day postoperative complication (OR: 4.44, 95%CI: 1.6-12.4, p < 0.05) after adjusting for gender. CONCLUSION: Preoperative sarcopenia is associated with increased 30-day postoperative complications following TaTME for rectal cancer. Postoperative complications can have serious oncologic implications by delaying adjuvant chemotherapy. Therefore, preoperative recognition of sarcopenia prior to undergoing TaTME for rectal cancer may provide an opportunity for early intervention with prehabilitation programs.

Oncologic Outcomes After Transanal Total Mesorectal Excision for Rectal Cancer.

BACKGROUND: Recent series have raised concerns about the oncologic outcomes of transanal total mesorectal excision for mid and low rectal cancer. There is a paucity of large data sets from the United States to contribute to the ongoing international discourse. OBJECTIVE: This study aimed to investigate the rate of local recurrence and other oncologic outcomes in patients undergoing transanal total mesorectal excision for rectal adenocarcinoma. DESIGN: This study is a retrospective review of patients undergoing transanal total mesorectal excision for primary rectal cancer from January 2014 to December 2019. SETTINGS: This study was conducted at a single academic tertiary care medical center in the United States. PATIENTS: Consecutive patients aged ≥18 years undergoing surgical resection for primary rectal cancer were selected. INTERVENTION: The transanal total mesorectal excision procedures were performed utilizing a 2-team approach. MAIN OUTCOME MEASURES: Primary outcomes were pathologic quality, local and distant recurrence, treatment-related complications, and overall- and cancer-specific survival. RESULTS: Seventy-nine consecutive patients were included. The median age was 58 years (interquartile range, 50-64), and median BMI was 28 kg/m2 (interquartile range, 24.6-32.4). The mesorectum was complete in 69 patients (87.3%), nearly complete in 9 (11.4%), and incomplete in 1 (1.3%). There was circumferential resection margin involvement (<1 mm) in 4 patients (5.1%), and no patients had a positive distal margin (<1 mm) or intraoperative rectal perforation. Composite optimal pathology was achieved in 94.9% of specimens. Median follow-up was 29 months (range, 6-68). There were no local recurrences. Distant metastases were found in 10 (13.5%) patients and diagnosed after a median of 14 months (range, 0.6-53). Disease-free survival was 91.2% at 2 years, and overall survival was 94.7% at 2 years. LIMITATIONS: Retrospective design, a single center, and relatively short follow-up period were limitations of this study. CONCLUSION: The oncologic outcomes of this cohort support the use of transanal total mesorectal excision in the surgical management of mid to low rectal cancer at centers with appropriate expertise. See Video Abstract at http://links.lww.com/DCR/B723. RESULTADOS ONCOLGICOS DESPUS DE LA EXCISIN TOTAL DEL MESORRECTO POR VA TRANSANAL EN CASOS DE CNCER RECTAL: ANTECEDENTES:Estudios recientes han suscitado preocupación sobre los resultados oncológicos de la excisión total del mesorecto por vía transanal en casos de cáncer de recto medio y bajo. Existe una gran escasez de conjuntos de datos en los Estados Unidos, para contribuir en el actual discurso internacional sobre el tema.OBJETIVO:Investigar la tasa de recurrencia local y otros resultados oncológicos en pacientes sometidos a una excisión total del mesorrecto por vía transanal por adenocarcinomas de recto.DISEÑO:Revisión retrospectiva de pacientes sometidos a excisión total del mesorecto por vía transanal en casos de cáncer de recto primario desde enero de 2014 hasta diciembre de 2019.AJUSTE:Centro médico Universitario de atención terciaria único en los Estados Unidos.PACIENTES:Aquellos pacientes consecutivos de ≥ 18 años de edad, sometidos a resección quirúrgica por cáncer de recto primario.INTERVENCIÓN:Los procedimientos de excisión total del mesorecto por vía transanal se realizaron utilizando un enfoque de dos equipos.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la calidad anatomo-patológica de las piezas, la recidiva local y a distancia, las complicaciones relacionadas con el tratamiento y la sobrevida global específica para el cáncer.RESULTADOS:Se incluyeron 79 pacientes consecutivos. La mediana de edades fue de 58 años (IQR, 50-64) y la mediana del índice de masa corporal fue de 28 kg / m (IQR, 24,6-32,4). El mesorrecto se encontraba completo en 69 pacientes (87,3%), casi completo en 9 (11,4%) e incompleto en 1 (1,3%). Hubo afectación de CRM (<1 mm) en 4 pacientes (5,1%) y ningún paciente tuvo un margen distal positivo (<1 mm) o perforación rectal intraoperatoria. La histopatología óptima compuesta se logró en el 94,9% de las muestras. La mediana de seguimiento fue de 29 meses (rango 6-68). No se presentaron recurrencias locales. Se encontraron metástasis a distancia en 10 (13,5%) pacientes y se diagnosticaron después de una mediana de 14 meses (rango 0,6-53). La sobrevida libre de enfermedad fue del 91,2% a los 2 años y la sobrevida global fue del 94,7% a los 2 años.LIMITACIONES:Diseño retrospectivo, unicéntrico y período de seguimiento relativamente corto.CONCLUSIÓN:Los resultados oncológicos de este estudio de cohortes, apoyan la realización de excisión total del mesorecto por vía transanal para el tratamiento quirúrgico del cáncer de recto medio y bajo, en centros con la experiencia adecuada. Consulte Video Resumen en http://links.lww.com/DCR/B723. (Traducción-Dr. Xavier Delgadillo).

Use of medical chaperones by colon and rectal surgeons in outpatient practice.

BACKGROUND: The purpose of this study is to determine the frequency and motivations for medical chaperone use during anorectal exams by colon and rectal surgeons in the outpatient setting. STUDY DESIGN: This cross-sectional study examined factors impacting chaperone use via an anonymous online survey distributed via the American Society of Colon and Rectal Surgeons email list. Routine chaperone use was defined as ≥ 90%. RESULTS: Of 1,380 emailed board-certified colon and rectal surgeons, 402 (29.1%) completed the survey in November 2019. Median years in practice was 14, and 72.3% were male. Overall, 65.2% reported routine use of chaperones during anorectal exams. Over half (56.3%) felt chaperones should be mandatory and were more likely to report routine use than those who did not (85.7 vs. 39.1%; p < 0.001). Only 23.7% reported that their institutions had formal chaperone policies. The most common reason for use was medicolegal (91.8%), and the most common barrier was chaperone availability (56.7%). When chaperones were used, 42% did not document use in the medical record. On multivariable analysis, increased odds of routine chaperone use were independently associated with: being ≤ 10 years in practice, routine chaperone use during fellowship, and chaperones being routinely available. CONCLUSION: Half of surgeons felt that chaperones should be mandatory, suggesting lack of consensus among the cohort. Despite expressing legal concerns, one-third did not use chaperones and nearly half who used chaperones did not document their use. Efforts to improve chaperone availability, documentation of chaperone use, and knowledge of policies are necessary.

Defining Anastomotic Leak and the Clinical Relevance of Leaks.

Surgeons universally dread gastrointestinal anastomotic leaks, yet the precise definition is not widely agreed on despite international consensus guidelines. Likewise, leaks are not uniformly reported which makes comparisons across studies flawed. Leak rates range from 1 to 3% for ileocolonic, 0.5 to 18% for colorectal, and 5 to 19% for coloanal anastomoses. The sequelae of an anastomotic leak vary but generally correlate with the need for a change in clinical management, from minimal changes to the need for reoperation. Short- and long-term outcomes can be life-altering or life-threatening. Temporary or permanent stomas may be necessary and low pelvic anastomotic leaks may affect bowel function. For cancer patients, leaks can delay treatment and negatively affect oncologic outcomes. In Crohn's patients, leaks are associated with higher recurrence rates. In essence, the lack of agreement on the definition of an anastomotic leak inhibits meaningful understand of its epidemiology, prevention, and treatment.

Diagnosis and Management of Chronic Anastomotic Leak.

Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.

Development of a Practice Guideline for Discharge Opioid Prescribing After Major Colorectal Surgery.

BACKGROUND: Better alignment of opioid prescription quantities with patient need could help reduce excessive prescribing. OBJECTIVE: The study sought to develop an institutional prescribing guideline based on defined opioid consumption patterns after inpatient colorectal operations. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients who underwent elective major colorectal procedures between July 2018 and January 2019 were included. MAIN OUTCOME MEASURES: The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills. RESULTS: Patients were categorized into 3 groups based on consumption in the 24-hour period before discharge: tier 1 consumed 0 equianalgesic oxycodone 5-mg pills (n = 53), tier 2 consumed 0.1 to 3.0 equianalgesic oxycodone 5-mg pills (n = 25), and tier 3 consumed >3.0 equianalgesic oxycodone 5-mg pills (n = 22). Average prescription quantity was 17.5 ± 10.5 equianalgesic oxycodone 5-mg pills (range, 0-78). Patients consumed a mean of 6.7 ± 10.9 equianalgesic oxycodone 5-mg pills after discharge and had 10.8 ± 10.2 equianalgesic oxycodone 5-mg pill excess, whereas 51% of patients consumed no pills. Opioid consumption was significantly different between each tier (p < 0.001). A prescribing guideline was developed to satisfy the majority of patients: 0 equianalgesic oxycodone 5-mg pills if tier 1, 12 pills if tier 2, and 30 pills if tier 3. Tiered guideline adoption could reduce prescribed pills by 45% and excess pills per prescription by 73%. Patient history of IBD was independently associated with increased odds of exceeding the guideline (adjusted OR = 7.2 (95% CI, 1.6-32.6)). LIMITATIONS: The study was limited by its single-center, retrospective design and that outpatient opioid consumption was self-reported. CONCLUSIONS: Following hospital discharge after major colorectal surgery, more than half of patients consumed no opioid pills, and 62% of prescribed opioids were in excess. Outpatient opioid consumption was highly associated with inpatient opioid use in the 24 hours before discharge. Prospective validation of this prescribing guideline is needed, but adoption could reduce excessive prescribing. See Video Abstract at http://links.lww.com/DCR/B575. DESARROLLO DE UNA GUA PRCTICA PARA LA PRESCRIPCIN DE OPIOIDES AL EGRESO DESPUS DE UNA CIRUGA COLORRECTAL MAYOR: ANTECEDENTES:Una mejor alineación de las cantidades de prescripción de opioides con las necesidades del paciente podría ayudar a reducir la prescripción excesiva.OBJETIVO:El estudio buscó desarrollar una guía institucional de prescripción basada en patrones definidos de consumo de opioides luego de cirugías colorrectales hospitalarias.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:El estudio se llevó a cabo en un solo centro de atención terciaria.PACIENTES:Pacientes que se sometieron a procedimientos colorrectales mayores electivos entre julio de 2018 y enero de 2019.PRINCIPALES MEDIDAS DE RESULTADO:El estudio midió las cantidades de prescripción y consumo medidas como píldoras de 5 mg de oxicodona equianalgésica (EOP).RESULTADOS:Los pacientes se clasificaron en tres grupos según el consumo en el período de 24 horas antes del egreso: el nivel 1 consumió 0 EOP (n = 53), el nivel 2 consumió 0,1-3 EOP (n = 25) y el nivel 3 consumió más de 3 EOP (n = 22). La cantidad promedio de prescripción fue 17,5 (± 10,5) EOP (rango: 0-78). Los pacientes consumieron una media de 6,7 (± 10,9) EOP posterior al egreso y tuvieron un exceso de 10,8 (± 10,2) EOP, mientras que el 51% de los pacientes no consumieron píldoras. El consumo de opioides fue significativamente diferente entre cada nivel (p <0,001). Se desarrolló una guía de prescripción para satisfacer a la mayoría de los pacientes: 0 EOP del nivel 1, 12 EOP del nivel 2 y 30 EOP del nivel 3. La adquisición de una guía escalonada podría reducir las píldoras recetadas en un 45% y el exceso de píldoras por receta en un 73%. El historial del paciente de enfermedad inflamatoria intestinal se asoció de forma independiente con un aumento de las probabilidades de superar la guía (ORa 7,2; IC del 95%: 1,6-32,6).LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo de un solo centro y por el consumo de opioides del paciente ambulatorio el cual fue autoinformado.CONCLUSIONES:Tras el egreso hospitalario de una cirugía colorrectal mayor, más de la mitad de los pacientes no consumieron pastillas opioides y el 62% de los opioides prescritos estaban en exceso. El consumo de opioides como paciente ambulatorio estuvo altamente asociado con el uso de opioides como paciente hospitalizado en las 24 horas previas al egreso. Se necesita una validación prospectiva de esta guía de prescripción, pero la adopción podría reducir la prescripción excesiva. Consulte Video Resumen en http://links.lww.com/DCR/B575.

Total Transperineal Laparoscopic Proctectomy for the Treatment of Crohn's Proctitis.

INTRODUCTION: Completion proctectomy is traditionally performed using a combination of abdominal and perineal approaches. Access to and exposure of the pelvis through the abdominal cavity can be limited in patients with prior surgery or inflammatory conditions. We describe a novel technique for a total transperineal approach for proctectomy for Crohn's proctitis, avoiding technical challenges, risks, and recovery associated with abdominal surgery. TECHNIQUE: We utilized the skills and expertise acquired from our experience with transanal total mesorectal excision to perform a total transperineal laparoscopic proctectomy in a male patient with medically refractory proctitis. He previously underwent an anterior resection, drainage of a chronic presacral abscess, omental pedicle flap transposition to the pelvis, and end colostomy for severe Crohn's colitis. The total transperineal laparoscopic proctectomy approach avoids the need for abdominal access, including the risks associated with abdominal entry, adhesiolysis, pelvic access and visualization, and wound-related issues. Following an initial intersphincteric perineal dissection, the GelPOINT Path minimal access platform is utilized to perform a total transperineal proctectomy. RESULTS: The patient recovered uneventfully and was discharged to home 2 days after surgery. At 1-month postoperative follow-up, the patient is recovering well with complete healing of the perineal wound. CONCLUSION: We demonstrate the feasibility, safety, and technical steps of a minimally invasive completion proctectomy for fistulizing Crohn's proctitis by using a total transperineal approach. This approach allowed us to utilize direct, inline, high-definition visualization to access and safely operate in the distal aspects of a narrow, scarred, and fibrotic pelvis while avoiding the need for any abdominal access. Advanced experience with redo pelvic and minimally invasive transanal surgery is critical. See Video at http://links.lww.com/DCR/B664.