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New developments in colorectal surgery

Mathis, Kellie L.; Boostrom, Sarah Y.; Pemberton, John H.

Current Opinion in Gastroenterology: January 2013 - Volume 29 - Issue 1 - p 72–78
doi: 10.1097/MOG.0b013e32835a34ea
LARGE INTESTINE: Edited by Ciarán P. Kelly

Purpose of review The field of colorectal surgery continues to move forward as technical innovations emerge and as surgeons ask critical questions. The results of subsequent investigations often lead to changes in practice. This review examines recent publications that describe these practice changes.

Recent findings We identified and reviewed recent publications in the areas of rectal cancer controversies, genetic risk profiling, practice improvements, diverticulitis, enhanced recovery protocols, fecal incontinence, and single incision laparoscopic surgery.

Summary New technologies and practice innovations will continue to enhance patient outcomes. Multiinstitutional studies, randomized when able, are necessary to further define the safety and efficacy of new surgical techniques and to further define best practices in colorectal surgery.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA

Correspondence to John H. Pemberton, MD, Mayo Clinic, Division of Colon and Rectal Surgery, Gonda 9 South, 200 First Street South West, Rochester, MN 55905, USA. Tel: +1 507 284 2359; e-mail:

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Over the past year, many publications report changes in the management of common colorectal surgery problems. We reviewed selected recent publications in the areas of rectal cancer controversies, genetic risk profiling, practice improvements, diverticulitis, enhanced recovery protocols, fecal incontinence, and single incision laparoscopic surgery.

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Neoadjuvant and adjuvant radiation therapy for rectal cancer is utilized to decrease local recurrence. However, variations in radiation therapy suggest that some patients may be treated with limited doses or none at all, specifically if not considered to be at high risk of local recurrence. Simunovic et al.[1▪] reviewed 96 patients, 46 of whom received preoperative radiation therapy for primary rectal cancer. The primary outcome was local recurrence in patients with and without radiation. There were four recurrences in the radiated group and two recurrences in the nonradiated group. When comparing patient and tumor variables, the risk of local recurrence was similar among groups, leading the authors to conclude that limiting preoperative radiation, even in patients with a threatened circumferential radial margin (CRM), does not compromise outcome.

At the other end of the spectrum of radiation therapy controversy is the question of interval from neoadjuvant treatment to surgery. Positive oncologic effects have been shown in patients with a pathologic complete response (pCR), and a higher rate of pCR has been achieved in patients with intervals greater than 8 weeks between radiation and surgery [2▪]. However, identification of those patients who are likely to respond and benefit from the longer intervals is difficult, and the exact interval for maximum benefit is yet to be determined. Clinical predictors of achieving pCR following neoadjuvant chemoradiation reveal a time interval greater than 8 weeks between treatment and surgery to be significant [3]. Recently, de Campos-Lobato et al.[4▪] reviewed 177 patients. There was no difference in perioperative complications. The patients with an interval equal to 8 weeks (n = 91) experienced a statistically significant improvement in pCR at 30.8 compared with 16.5% in the group with an interval less than 8 weeks (n = 86). The longer interval group also had a significantly reduced 3-year local recurrence rate of 1.2%, compared with the 10.5% recurrence rate of the shorter interval group. Thus, an interval equal to 8 weeks between neoadjuvant chemoradiation and surgery for rectal cancer appears well tolerated and is associated with an improved rate of pCR and decreased local recurrence.

Box 1

Box 1

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Controversy has been raised regarding patient positioning for the perineal portion of the abdominoperineal resection (APR). Prone positioning has been compared with lithotomy in terms of CRM, bowel perforation, and subsequent oncologic outcome. Tayyab et al.[5▪] reviewed 63 APR cases in the lithotomy position and 58 in the prone position. The 5-year local recurrence rate was 5% in the prone group and 23% in the lithotomy group (statistically significant). The authors conclude that the rate of local recurrence after APR may be reduced by utilizing the prone position. In contrast, de Campos-Lobato et al. reviewed 168 patients who underwent APR (81 prone, 87 lithotomy). The rate of iatrogenic bowel perforation was 2.4% for lithotomy patients and 4.6% for prone patients (not statistically significant). The percentage of patients with a CRM <1 mm was 13.8% for the lithotomy group compared with 8.6% in the prone group. The 5-year local recurrence rate was 5.7% for lithotomy and 14.4% prone groups (not statistically significant). The authors conclude that surgical positioning during the APR does not affect oncologic outcomes and the decision should be left to the discretion of the operating surgeon. Outcomes are likely a direct result of surgeon skill and training and not of patient position [4▪].

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CRM positivity and tumor perforation are risk factors for local recurrence following standard APR. The extralevator approach (removing the levator muscles en bloc) avoids the ‘coning down’ effect that may occur in a standard APR [6▪]. A recent study compares the extralevator approach in 176 patients to the standard APR in 124 patients, reporting that CRM positivity decreased from 49.6 to 20.3%. The intraoperative bowel perforation rate also decreased from 28.2 to 8.2%; the perforation rate was lowest when the perineal phase was performed in the prone position (6 vs. 20% for lithotomy). However, the extralevator approach was associated with increased wound complications (38 vs. 20%). The authors conclude that the extralevator approach to APR is associated with decreased CRM positivity and fewer intraoperative bowel perforations; however, the rate of wound complications is increased significantly [7]. We would note that these reported rates of positive CRM and bowel perforation seem extraordinarily high, more than 10-fold the rates at our institution.

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Neoadjuvant chemoradiation is known to downstage tumors and to decrease rates of local recurrence. Responses range from no tumor effect to pCR, which occurs in up to 20%. pCR is an important prognostic factor, but the method of determining pCR is variable and imprecise [8–10]. Furthermore, in such instances of a presumed but incorrect pCR, less extensive operations or nonoperative approaches would greatly compromise oncologic outcome. Thus, the identification of patients with a true pCR is of great importance when determining treatment algorithms. It remains unclear as to which method is best for detecting pCR, how frequently patients should be evaluated after pCR, and characteristics of recurrence following pCR. Thus, the practice of a nonoperative approach after a complete response to chemoradiotherapy (also known as the ‘wait and see’ approach) remains controversial.

It has been suggested that any positive lymph nodes following neoadjuvant chemoradiation in patients downstaged to ypT0 (pathologic stage T0 following neoadjuvant therapy) carries worse oncologic outcomes. Capirci et al.[11] described 566 patients downstaged to ypT0N0 following chemoradiation; only 1.6% developed a local recurrence, 0.4% in the clinically node negative group, and 2.4% in the patients with positive lymph nodes before therapy. Therefore, some argue that lymph nodes positivity has minimal influence on local recurrence in patients whose tumors are downstaged to ypT0. Proponents of local excision argue that lymph nodes positivity is estimated to be 5–10% and tumors downstaged to ypT0 are unlikely to recur locally (more likely to develop distant disease). Additionally, if ypT0 status and clear margins are obtained, local excision provides comparable oncological outcomes to radical surgery. Those against this concept argue that the only way to know the true lymph nodes status is radical resection. Local excision implies that the mesorectal lymph nodes are left behind, underestimating positivity. A proposed method to minimize the risk of performing local excision on ypT0N+ patients is to select only those patients who are N0 prior to any treatment [12–14].

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High-resolution MRI has become an important modality for preoperative staging of rectal cancers. Advantages include the ability to view three-dimensional relationships and the ability to estimate the CRM, vascular invasion and lymph nodes involvement [15,16]. The use of MRI to classify tumor response to neoadjuvant therapy to determine pCR has been reported by Chang et al.[17▪▪]. Sixty-two patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation were evaluated after therapy. Depth of mesorectum penetration and lymph nodes involvement were both associated with poor tumor response and CRM involvement by MRI was associated with a final pathological diagnosis of close CRM (<1 mm). The MRI results were then utilized to stratify patients as ‘good’ or ‘poor’ risk for response to neoadjuvant therapy. Lambregts et al.[18▪▪] described rectal wall MRI morphology in short-term and long-term follow-up in 19 patients selected as pCR following chemoradiation for locally advanced rectal cancer. These patients were managed with the ‘wait and see’ algorithm and underwent clinical examination, endoscopy/biopsy, and rectal MRI every 3–6 months. Four patterns of rectal wall involvement were identified on MRI and were consistent with a pCR following chemoradiation. The authors conclude that these MRI features may be utilized as a reference during the close surveillance of patients managed with the ‘wait and see’ method.

In attempts to validate the utilization of endoscopic ultrasound as a predictor of pCR, Pastor et al.[19▪] reviewed images of 235 patients who underwent chemoradiation followed by surgical resection of rectal cancer. Tumor downstaging occurred in 23% and nodal downstaging occurred in 47%. When compared with the histopathology, endoscopic ultrasound correctly predicted T stage in 54% and N stage in 75%. The authors conclude that a proportion of patients continue to be misclassified based on ultrasound imaging, so endoscopic ultrasound should not be the diagnostic modality of choice when determining which patients are candidates for the ‘wait and see’ approach.

Similarly, Ruby et al.[20▪] reported on PET assessment of rectal cancer response to neoadjuvant therapy. One hundred and twenty seven patients with locally advanced rectal cancer underwent PET scans before and after neoadjuvant chemoradiation. The authors concluded that PET provides no prognostic information in assessment of rectal cancer response to neoadjuvant therapy.

In efforts to determine if histopathological techniques accurately detect pCR, Chen et al.[21▪] compared a molecular approach to current histopathological approaches in patients undergoing neoadjuvant chemoradiation followed by surgical resection for locally advanced rectal cancer. They looked for k-ras and p-53 mutations in 96 pretreatment biopsies and again in the surgical specimens after resection. Of the 12 patients who had pCR by histology, two still had k-ras (n = 1) or p-53 (n = 1) remaining in the specimen, suggesting that the histologic technique may be insufficient to determine pCR.

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Laparoscopic proctectomy for cancer is being studied in a multiinstitutional randomized trial currently [22▪▪]. Greenblatt et al.[23▪▪] used the National Surgical Quality Improvement Project (NSQIP) database to compare hospital length of stay (LOS) and short-term morbidity between groups of patients undergoing laparoscopic (n = 1040) and open proctectomy (n = 4380) from 2005 to 2009. They found that surgical site infections (SSIs), sepsis, respiratory complications, renal failure, and venous thromboembolism were each lower in the laparoscopic group. Additionally, the median LOS was 2 days shorter in the laparoscopic group (5 vs. 7 days).

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Although the incidence of colorectal cancer has been decreasing since the incorporation of screening colonoscopy programs, Davis et al.[24▪] found that colorectal cancer among Americans ages 40–44 is increasing (increased 67% since 1988). They suggest that consideration should be given to starting screening at age 40 [24▪].

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Gene expression profiling has been used increasingly in an effort to individualize treatment for various benign and malignant diagnoses. Levine et al.[25▪] describe global gene expression analysis that they performed on 47 tissue samples from patients undergoing surgery for appendiceal and colorectal cancers. They found three distinct phenotypes among the samples and each was associated with distinct survival probabilities. The authors conclude that these phenotypes appear to predict survival and may be used to guide patient management.

Another example of this has been described in Crohn's disease. One group studied 30 patients with Crohn's disease that required one or more ileocecal resections during 15-year follow-up. Patients with a mutation in the IGRM gene had an average of 1 ileocolic resection every 6.9 years when compared with patients without that mutation who had one surgery every 11.4 years [26▪]. The same group of authors has identified mutations that are associated with Crohn's disease-like complications after ileal pouch-anal anastomosis (IPAA) and others that are associated with severe pouchitis. These markers could be used in the future to predict patients preoperatively who may have complications after IPAA [27▪].

Similar work has been done in rectal cancer. Leong et al.[28▪] looked for hypermethylation at specific loci of 24 tumor suppressor genes in rectal cancer specimens. They found that hypermethylation was more common in early-stage disease (N0, M0). These biomarkers could eventually be used to determine which patients are acceptable candidates for nonradical procedures. Others identified a biomarker profile that is strongly associated with a nonpCR after chemoradiotherapy [29▪].

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One method surgeons have used to improve outcomes is to adopt best practice protocols. A multiinstitutional group of surgeons in Tennessee formed a collaborative group to review surgical outcomes. After 1 year of collaborative discussions, they found significant improvements in SSI, ventilator days, graft failure, acute renal failure, and wound disruption among their hospitals according to NSQIP data [30▪].

Ruiz-Tovar et al.[31▪▪] performed a randomized trial comparing intraabdominal irrigation with normal saline (standard therapy at their institution) with lavage using antibiotic-infused saline (treatment group) after completion of an elective operation for a colorectal neoplasm. Wound infection and abscess rates were considerably lower in the group receiving lavage with clindamycin and gentamicin solution.

Al-Refaie et al.[32▪] used the NSQIP database to study the effects of old age on outcomes following colorectal surgery. Not surprisingly, they found that patients more than 80 years were more likely than their younger counterparts to experience 30-day mortality, major complications, and prolonged LOS after both open and laparoscopic procedures. This is important as the number of patients we see greater than 80 years of age grows [32▪]. Postoperative hyperglycemia in both diabetics and nondiabetics has been shown to increase the risk of postoperative complications and death after colectomy in the Veteran Affairs database [33▪]. Billeter et al.[34▪] reported a nationwide study of greater than 85 000 US patients undergoing colectomy in teaching hospitals from 2005 to 2011. They found an overall mortality rate of 1.56%, suggesting that colectomy is well tolerated.

Steinhagen et al.[35▪] describe a reflex protocol they implemented to screen all patients less than 50 years with a new colorectal cancer diagnosis for Lynch syndrome. They found 10 patients with Lynch out of 198 screened. Only 20% of these patients met the Amsterdam criteria and would have been diagnosed otherwise.

Gervaz et al.[36▪] used a cohort of 534 patients undergoing colorectal surgical resections to develop a scoring system that would predict SSI. They found that the four most important factors were obesity, contamination class three or four, American Society of Anesthesiologists grade III or IV, and open surgery. If one factor is present, the observed risk was 12%. If all four factors were present the observed risk of SSI was 68%.

Gorissen et al.[37▪] compared anastomotic leak rates among all patients undergoing a colorectal anastomosis from 2008 to 2010 at two teaching institutions. They grouped the patients by NSAID use, and they found that patients receiving nonselective NSAIDs were more likely to experience an anastomotic leak (14.5 vs. 9% for COX-2 inhibitors). Because NSAIDs are a common component of fast track and enhanced recovery protocols, the authors suggest further studies to defend or refute these findings.

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Medical therapy for ulcerative colitis is costly. Park et al.[38▪] examined the cost-effectiveness of early colectomy and IPAA and compared it with standard medical therapy. They used a Markov model and found a lifetime cost of US$ 236 370 per patient for medical therapy compared with US$ 147 763 per patient for immediate colectomy after the diagnosis of ulcerative colitis. They concluded that early IPAA after diagnosis of severe ulcerative colititis reduces healthcare costs and offers a comparable quality of life compared with standard medical therapy.

Hull et al.[39▪] assessed patients for number and extent of intraabdominal adhesions using diagnostic laparoscopy at the time of diverting loop ileostomy closure after IPAA. Twenty-eight had undergone a laparoscopic IPAA and 12 had undergone an open approach to IPAA. Not surprisingly, they found that patients in the laparoscopy group had significantly fewer incisional adhesions as well as total abdominal and adnexal adhesions.

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Several controversies continue regarding the management of uncomplicated diverticulitis. In North America, the mainstay of treatment is antibiotics, and this treatment is recommended by many society guidelines. De Korte et al.[40▪▪] aimed to review the evidence for the use of antibiotics. They found very few prospective reports, and the ones that did exist were of low quality. The authors concluded that high-quality prospective studies should be performed to confirm or refute current management guidelines. A case–control study was performed by the same authors with 191 patients given no antibiotics and 81 patients receiving antibiotics for a diagnosis of imaging-confirmed uncomplicated diverticulitis. Treatment success was the same among groups [41▪]. A randomized trial comparing antibiotics vs. no antibiotics for the management of acute uncomplicated diverticulitis performed across 10 institutions was recently reported. The rate of complications was not significantly different (1.9% in the no antibiotic group and 1.0% in the antibiotic group). The median LOS was 3 days in each group, and the rate of recurrent diverticulitis requiring hospital admission was also the same in the two groups. The authors conclude that there is no benefit to routine antibiotic administration for uncomplicated diverticulitis [42▪▪].

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Abraham-Nordling et al.[43▪▪] assessed the benefits of perioperative fluid restriction. They randomized fast-track patients (preoperative interventions, optimizing analgesia, early enteral feeding, and early mobilization) to a restricted fluid protocol (n = 79) or to a standard fluid protocol (n = 82). They found no difference in LOS, but patients in the fluid restriction group experienced significantly fewer complications.

Delaney et al.[44▪▪] reported their series of 1000 consecutive laparoscopic colorectal resections using an enhanced recovery pathway. Although they do not have a comparative group, they have impressive results with an overall mortality of 0.3%, anastomotic leak rate of 1.4%, LOS of 4.1 days, and a readmission rate of 6%.

Lovely et al.[45▪] case-matched patients undergoing laparoscopic colorectal surgery under an enhanced recovery protocol (preoperative analgesia, fluid and opiate restriction, early enteral feeding, and early mobilization) with patients treated with a fast-track protocol (early enteral feeding and mobilization only). They found that the enhanced protocol further decreased the LOS. Forty-four percent of enhanced recovery program patients left the hospital in 2 days (vs. 8% of the fast-track patients). Thirty-day complications and readmission rates were not different between groups.

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Ratto et al.[46▪] describe their results with a new bulking agent placed in the intersphincteric plane for the treatment of fecal incontinence. Fourteen patients had the implantation under local anesthesia using ultrasound guidance. At a mean follow-up of 33 months, there were no complications and the mean number of major fecal incontinence episodes had decreased from a baseline of 7.1 to 0.4 per week. This is a promising finding and deserves further study.

A group of surgeons reported their long-term results with the artificial bowel sphincter in 52 patients. With a mean follow-up of 64 months, 50% of patients had required a revision and 27% required explantation. In 35 patients with a working device in place, they reported significant improvements in the Wexner fecal incontinence score and quality of life scores as compared with baseline preimplant scores [47▪].

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Multiport laparoscopy has been widely adopted for most benign colorectal surgical indications and for some malignant indications. Many groups have tried single incision laparoscopic surgery (SILS) to further improve cosmesis and to perhaps improve outcomes after colorectal surgery. Waters et al.[48▪] described a case series of 100 consecutive SILS right colectomies. Rijcken et al.[49▪] matched 20 consecutive Crohn's disease patients undergoing SILS ileocecectomy with 20 similar patients undergoing the same operation with a multiport technique. They found similar conversion rates, morbidity, pain scores, and LOS between groups. Champagne et al.[50▪▪] case-matched patients from five institutions undergoing single-incision (n = 165) vs. multiport laparoscopic colectomy (n = 165). They found that SILS was safe but outcomes were similar between the two groups. A group of Korean surgeons performed a similar comparison for patients undergoing SILS (n = 73) vs. conventional multiport surgery (n = 106) for colon and rectal cancers. They found less pain and shorter LOS in the SILS group [51▪]. Makino et al.[52▪▪] performed a systematic review of all reports of SILS colectomy in the modern literature (n = 378). The overall conversion rate to another technique was 6.9%. Four of the included studies were case-matched to other minimally invasive techniques, and two studies showed a shorter LOS following SILS. One study showed significantly lower postoperative pain scores in the SILS group.

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New technologies and practice innovations will continue to enhance patient outcomes following colonic and rectal surgery. Multiinstitutional studies, randomized when possible, are necessary to further define the safety and efficacy of new surgical techniques and to further define best practices.

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Conflicts of interest

The authors have no conflicts of interest to report in relation to the preparation of this manuscript.

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Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 103).

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1▪. Simunovic M, Jacob S, Coates AJ, et al. Outcomes following a limited approach to radiotherapy in rectal cancer. Br J Surg 2011; 98:1483–1488.

The authors analyzed local recurrence in patients with stage I or II tumors receiving preoperative radiation and compared it with those not receiving radiation. The impact of a positive or close radial margin was also assessed as it related to recurrence.

2▪. de Campos-Lobato LF, Geisler DP, da Luz Moreira A, et al. Neoadjuvant therapy for rectal cancer: the impact of longer interval between chemoradiation and surgery. J Gastrointest Surg 2011; 15:444–450.

The authors compared the effects of preoperative radiation on morbidity and oncologic outcome in patients undergoing surgery at an interval of less than 8 weeks compared with those at an interval of more than 8 weeks after completion.

3. Kalady MF, de Campos-Lobato LF, Stocchi L, et al. Predictive factors of pathologic complete response after neoadjuvant chemoradiation for rectal cancer. Ann Surg 2009; 250:582–589.
4▪. de Campos-Lobato LF, Stocchi L, Dietz DW, et al. Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes. Dis Colon Rectum 2011; 54:939–946.

This single institution study describes 168 patients undergoing APR in the prone vs. Lloyd-Davies position, comparing oncologic outcomes based on position.

5▪. Tayyab M, Sharma A, Ragg JL, et al. Evaluation of the impact of implementing the prone jackknife position for the perineal phase of abdominoperineal excision of the rectum. Dis Colon Rectum 2012; 55:316–321.

This single institution study compares 121 patients undergoing APR in the prone vs. Lloyd-Davies position based on local recurrence rates and survival.

6▪. Acar HI, Kuzu MA. Perineal and pelvic anatomy of extralevator abdominoperineal excision for rectal cancer: cadaveric dissection. Dis Colon Rectum 2011; 54:1179–1183.

This article describes the anatomical planes for standard APR vs. the extralevator dissection.

7. West NP, Anderin C, Smith KJ, et al. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 2010; 97:588–599.
8. Das P, Skibber JM, Rodriguez-Bigas MA, et al. Clinical and pathologic predictors of locoregional recurrence, distant metastasis, and overall survival in patients treated with chemoradiation and mesorectal excision for rectal cancer. Am J Clin Oncol 2006; 29:219–224.
9. Garcia-Aguilar J, Hernandez de Anda E, Sirivongs P, et al. A pathologic complete response to preoperative chemoradiation is associated with lower local recurrence and improved survival in rectal cancer patients treated by mesorectal excision. Dis Colon Rectum 2003; 46:298–304.
10. Maas M, Nelemans PJ, Valentini V, et al. Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol 2010; 11:835–844.
11. Capirci C, Valentini V, Cionini L, et al. Prognostic value of pathologic complete response after neoadjuvant therapy in locally advanced rectal cancer: long-term analysis of 566 ypCR patients. Int J Radiat Oncol Biol Phys 2008; 72:99–107.
12. Yeo SG, Kim DY, Kim TH, et al. Pathologic complete response of primary tumor following preoperative chemoradiotherapy for locally advanced rectal cancer: long-term outcomes and prognostic significance of pathologic nodal status (KROG 09-01). Ann Surg 2010; 252:998–1004.
13. Read TE, Andujar JE, Caushaj PF, et al. Neoadjuvant therapy for rectal cancer: histologic response of the primary tumor predicts nodal status. Dis Colon Rectum 2004; 47:825–831.
14. Smith FM, Waldron D, Winter DC. Rectum-conserving surgery in the era of chemoradiotherapy. Br J Surg 2010; 97:1752–1764.
15. Heald RJ, O’Neill BD, Moran B, et al. MRI in predicting curative resection of rectal cancer: new dilemma in multidisciplinary team management. BMJ 2006; 333:808.
16. Smith NJ, Barbachano Y, Norman AR, et al. Prognostic significance of magnetic resonance imaging-detected extramural vascular invasion in rectal cancer. Br J Surg 2008; 95:229–236.
17▪▪. Chang GJ, You YN, Park IJ, et al. Pretreatment high-resolution rectal MRI and treatment response to neoadjuvant chemoradiation. Dis Colon Rectum 2012; 55:371–377.

This retrospective review aimed to evaluate the ability of pretreatment rectal MRI to classify tumor response to neoadjuvant chemoradiation, specifically with regard to mesorectal tumor depth, lymph node status, extraural vascular invasion, and grade.

18▪▪. Lambregts DM, Maas M, Bakers FC, et al. Long-term follow-up features on rectal MRI during a wait-and-see approach after a clinical complete response in patients with rectal cancer treated with chemoradiotherapy. Dis Colon Rectum 2011; 54:1521–1528.

This observational study of 19 selected patients aimed to describe the rectal wall morphology by MRI in patients with a clinical complete tumor response undergoing a wait-and-see policy without surgical intervention.

19▪. Pastor C, Subtil JC, Sola J, et al. Accuracy of endoscopic ultrasound to assess tumor response after neoadjuvant treatment in rectal cancer: can we trust the findings? Dis Colon Rectum 2011; 54:1141–1146.

This observational cohort study of 235 patients undergoing chemoradiation therapy aimed to validate the use of endoscopic ultrasound as a predictor of clinical and pathological tumor response in patients with locally advanced rectal cancer.

20▪. Ruby JA, Leibold T, Akhurst TJ, et al. FDG-PET assessment of rectal cancer response to neoadjuvant chemoradiotherapy is not associated with long-term prognosis: a prospective evaluation. Dis Colon Rectum 2012; 55:378–386.

This study of 127 patients with locally advanced rectal cancer aimed to evaluate the ability of PET to predict long-term prognosis based on the response to neoadjuvant chemoradiation.

21▪. Chen Z, Duldulao MP, Li W, et al. Molecular diagnosis of response to neoadjuvant chemoradiation therapy in patients with locally advanced rectal cancer. J Am Coll Surg 2011; 212:1008–1017.

This study evaluated a molecular approach for detecting complete pathological response and compared it with current histopathological approaches in 96 patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation.

22▪▪. Baik SH, Gincherman M, Mutch MG, et al. Laparoscopic vs open resection for patients with rectal cancer: comparison of perioperative outcomes and long-term survival. Dis Colon Rectum 2011; 54:6–14.

This phase II pilot study aimed to assess the safety and oncologic feasibility of laparoscopic-assisted resection for rectal cancer vs. open rectal resection as a planned randomized clinical trial.

23▪▪. Greenblatt DY, Rajamanickam V, Pugely AJ, et al. Short-term outcomes after laparoscopic-assisted proctectomy for rectal cancer: results from the ACS NSQIP. J Am Coll Surg 2011; 212:844–854.

This article utilizes the NSQIP database to compare hospital LOS and short-term morbidity between groups of patients undergoing laparoscopic vs. open proctectomy from 2005 to 2009.

24▪. Davis DM, Marcet JE, Frattini JC, et al. Is it time to lower the recommended screening age for colorectal cancer? J Am Coll Surg 2011; 213:352–361.

The authors used a national database (SEER) to calculate the incidence of colon and rectal cancers among all age groups in the United States from 1987 to 2006.

25▪. Levine EA, Blazer DG 3rd, Kim MK, et al. Gene expression profiling of peritoneal metastases from appendiceal and colon cancer demonstrates unique biologic signatures and predicts patient outcomes. J Am Coll Surg 2012; 214:599–606.

This is a retrospective study done on a prospective cohort of patients with peritoneal metastases using gene expression analysis of the tissue to predict outcomes.

26▪. Sehgal R, Berg A, Polinski JI, et al. Mutations in IRGM are associated with more frequent need for surgery in patients with ileocolonic Crohn's disease. Dis Colon Rectum 2012; 55:115–121.

This is a retrospective review of 66 patients with Crohn disease, using genetic profiling to predict Crohn's severity.

27▪. Sehgal R, Berg A, Polinski JI, et al. Genetic risk profiling and gene signature modeling to predict risk of complications after IPAA. Dis Colon Rectum 2012; 55:239–248.

The authors performed a retrospective study using gene expression profiling to predict complications (pouchitis and Crohn's-like complications) following ileal pouch-anal anastomosis for ulcerative colitis.

28▪. Leong KJ, Wei W, Tannahill LA, et al. Methylation profiling of rectal cancer identifies novel markers of early-stage disease. Br J Surg 2011; 98:724–734.

The authors performed a retrospective study comparing methylation patterns of tumor suppressor genes in rectal cancer by hostologic stage.

29▪. Garcia-Aguilar J, Chen Z, Smith DD, et al. Identification of a biomarker profile associated with resistance to neoadjuvant chemoradiation therapy in rectal cancer. Ann Surg 2011; 254:486–492.

This is a single institution retrospective review of locally advanced rectal cancer pre and posttreatment specimens. The authors identified biomarkers that were predictive of complete pathologic response.

30▪. Guillamondegui OD, Gunter OL, Hines L, et al. Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to improve surgical outcomes. J Am Coll Surg 2012; 214:709–714.

This is a multiinstitutional review of National Surgical Quality Improvement Program data across 10 hospitals in Tennessee. The authors compared surgical outcomes before and after a regional surgical quality collaborative was formed.

31▪▪. Ruiz-Tovar J, Santos J, Arroyo A, et al. Effect of peritoneal lavage with clindamycin-gentamicin solution on infections after elective colorectal cancer surgery. J Am Coll Surg 2012; 214:202–207.

This is a small, randomized controlled study comparing peritoneal irrigation with normal saline (standard procedure) to antibiotic-infused irrigation solution following elective curative surgery for colorectal neoplasms.

32▪. Al-Refaie WB, Parsons HM, Habermann EB, et al. Operative outcomes beyond 30-day mortality: colorectal cancer surgery in oldest old. Ann Surg 2011; 253:947–952.

The authors performed a database review using the American College of Surgeons National Quality Improvement Project data to compare surgical outcomes by patient age.

33▪. Jackson RS, Amdur RL, White JC, Macsata RA. Hyperglycemia is associated with increased risk of morbidity and mortality after colectomy for cancer. J Am Coll Surg 2012; 214:68–80.

The authors performed a database review using the Veterans Affairs Surgical Quality Improvement Program data to compare surgical outcomes by blood glucose level.

34▪. Billeter AT, Polk HC Jr, Hohmann SF, et al. Mortality after elective colon resection: the search for outcomes that define quality in surgical practice. J Am Coll Surg 2012; 214:436–443.

The authors performed a database review using the University HealthSystem Consortium data to compare surgical mortality after colorectal surgery among teaching and nonteaching hospitals in the United States.

35▪. Steinhagen E, Shia J, Markowitz AJ, et al. Systematic immunohistochemistry screening for Lynch syndrome in early age-of-onset colorectal cancer patients undergoing surgical resection. J Am Coll Surg 2012; 214:61–67.

The authors describe their prospective database of a reflex institutional protocol for testing all early onset colorectal cancers for microsatellite instability.

36▪. Gervaz P, Bandiera-Clerc C, Buchs NC, et al. Scoring system to predict the risk of surgical-site infection after colorectal resection. Br J Surg 2012; 99:589–595.

The authors describe their methods to develop a clinical score to predict SSIs after colorectal surgery.

37▪. Gorissen KJ, Benning D, Berghmans T, et al. Risk of anastomotic leakage with nonsteroidal anti-inflammatory drugs in colorectal surgery. Br J Surg 2012; 99:721–727.

The authors used patient data at two university hospitals to determine risk factors for anastomotic leak after colorectal surgery. Their specific interest was the association between NSAID use postoperatively and anastomotic leak.

38▪. Park KT, Tsai R, Perez F, et al. Cost-effectiveness of early colectomy with ileal pouch-anal anastamosis versus standard medical therapy in severe ulcerative colitis. Ann Surg 2012; 256:117–124.

The authors compare the cost-effectiveness of early colectomy vs. aggressive medical management of newly diagnosed severe ulcerative colitis using a Markov model.

39▪. Hull TL, Joyce MR, Geisler DP, Coffey JC. Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis. Br J Surg 2012; 99:270–275.

The authors prospectively measured the number of adhesions present after surgery for ulcerative colitis. They specifically compared outcomes between laparoscopic and open approaches.

40▪▪. de Korte N, Unlu C, Boermeester MA, et al. Use of antibiotics in uncomplicated diverticulitis. Br J Surg 2011; 98:761–767.

The authors attempt to perform a systematic review of the use of antibiotics for the management of uncomplicated diverticulitis.

41▪. de Korte N, Kuyvenhoven JP, van der Peet DL, et al. Mild colonic diverticulitis can be treated without antibiotics. A case-control study. Colorectal Dis 2012; 14:325–330.

The authors perform a retrospective case–control study to compare outcomes with and without antibiotics in patients with mild diverticulitis.

42▪▪. Chabok A, Pahlman L, Hjern F, et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012; 99:532–539.

This is a multicenter randomized controlled trial comparing antibiotics and no antibiotics for the management of uncomplicated diverticulitis.

43▪▪. Abraham-Nordling M, Hjern F, Pollack J, et al. Randomized clinical trial of fluid restriction in colorectal surgery. Br J Surg 2012; 99:186–191.

The authors performed a randomized controlled trial comparing fluid restriction and liberal fluid use in the perioperative period following colorectal surgery. The primary endpoint was the hospital LOS.

44▪▪. Delaney CP, Brady K, Woconish D, et al. Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways. Am J Surg 2012; 203:353–355.

This is a large single institution cohort study of 1000 consecutive patients undergoing laparoscopic colectomy in the context of an enhanced recovery protocol.

45▪. Lovely JK, Maxson PM, Jacob AK, et al. Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. Br J Surg 2012; 99:120–126.

This is a single institution case-matched study comparing short-term outcomes after colorectal surgery in the context of an enhanced recovery pathway vs. a standard recovery pathway.

46▪. Ratto C, Parello A, Donisi L, et al. Novel bulking agent for faecal incontinence. Br J Surg 2011; 98:1644–1652.

The authors describe the se of a new bulking agent for the treatment of fecal incontinence in 14 patients.

47▪. Wong MT, Meurette G, Wyart V, et al. The artificial bowel sphincter: a single institution experience over a decade. Ann Surg 2011; 254:951–956.

This is a single institution experience with the artificial bowel sphincter in 52 patients.

48▪. Waters JA, Rapp BM, Guzman MJ, et al. Single-port laparoscopic right hemicolectomy: the first 100 resections. Dis Colon Rectum 2012; 55:134–139.

This is the largest single experience with single-port laparoscopic right hemicolectomy.

49▪. Rijcken E, Mennigen R, Argyris I, et al. Single-incision laparoscopic surgery for ileocolic resection in Crohn's disease. Dis Colon Rectum 2012; 55:140–146.

This is a single institution study comparing 20 patients undergoing single incision laparoscopic ileocolectomy for Crohn's disease with 20 historical controls undergoing open ileocolectomy.

50▪▪. Champagne BJ, Papaconstantinou HT, Parmar SS, et al. Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg 2012; 255:66–69.

This is a multicenter study comparing single incision vs. multiport laparoscopic colectomy.

51▪. Kim SJ, Ryu GO, Choi BJ, et al. The short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer. Ann Surg 2011; 254:933–940.

This is a single institution retrospective study comparing outcomes for single incision vs. multiport laproscopic surgery for cancer of the colon or rectum.

52▪▪. Makino T, Milsom JW, Lee SW. Feasibility and safety of single-incision laparoscopic colectomy: a systematic review. Ann Surg 2012; 255:667–676.

colon; rectum; surgery

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